Provider Demographics
NPI:1669611174
Name:MOTT III, CHARLES W (LMSW)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:MOTT III
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MAIN ST FL 4
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-6606
Mailing Address - Country:US
Mailing Address - Phone:607-756-4167
Mailing Address - Fax:607-753-0608
Practice Address - Street 1:17 MAIN ST FL 4
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-6606
Practice Address - Country:US
Practice Address - Phone:607-756-4167
Practice Address - Fax:607-753-0608
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071326101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02525840Medicaid