NPIMap

Organization Active NPI

Ontario County

  • Social Worker
  • Canandaigua, NY
National Provider Identifier
1003802190
Registry record updated Apr 1, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Social WorkerTaxonomy code 104100000X
License
6879100A Issued in NY
Legal business name
ONTARIO COUNTY
Practice address
3019 County Complex Dr
Canandaigua, NY 14424-9505
Phone
(585) 396-4363
Fax
(585) 396-4993
NPI assigned
Sep 23, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 1, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Jessica Mitchell, PHDNPI 1447508791
Title
Director
Phone
(585) 396-4363

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103T00000X 6879100A NY
Clinical PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103TC0700X 6879100A NY
Social WorkerGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 104100000X 6879100A NY Primary
Clinical Social WorkerGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 1041C0700X 6879100A NY
Psychiatry PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 2084P0800X 6879100A NY
Nurse PractitionerGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 363L00000X 6879100A NY

Addresses

Primary practice location

3019 County Complex Dr
Canandaigua, NY 14424-9505

Mailing address

3019 County Complex Dr
Canandaigua, NY 14424-9505
Phone (585) 396-4363

Other identifiers 5

IdentifierTypeStateIssuer
00357846MedicaidNY
014003729OtherNYMENTAL HEALTH OUTPATIENT
103283EUOtherNYMENTAL HEALTH OUTPATIENT
EMOtherNYMENTAL HEALTH OUTPATIENT
3109089OtherNYMENTAL HEALTH OUTPATIENT

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040719000682 NY Part B Supplier - Clinic/Group Practice 3779482252 Receives reassigned benefits from 21 practitioners
1 other NPI on this enrollment
Practice locations: Canandaigua, NY

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Ontario County LT Home Health Agency9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 21

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 21

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1127433600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1617235200000",
    "number": "1003802190",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3019 COUNTY COMPLEX DR",
            "city": "CANANDAIGUA",
            "state": "NY",
            "postal_code": "144249505",
            "telephone_number": "585-396-4363",
            "fax_number": "585-396-4993"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3019 COUNTY COMPLEX DR",
            "city": "CANANDAIGUA",
            "state": "NY",
            "postal_code": "144249505",
            "telephone_number": "585-396-4363",
            "fax_number": "585-396-4993"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ONTARIO COUNTY",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-09-23",
        "last_updated": "2021-04-01",
        "certification_date": "2021-04-01",
        "status": "A",
        "authorized_official_last_name": "MITCHELL",
        "authorized_official_first_name": "JESSICA",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "585-396-4363",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": "NY",
            "license": "6879100A",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": "NY",
            "license": "6879100A",
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Social Worker",
            "state": "NY",
            "license": "6879100A",
            "primary": true
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": "NY",
            "license": "6879100A",
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NY",
            "license": "6879100A",
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": "NY",
            "license": "6879100A",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00357846",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MENTAL HEALTH OUTPATIENT",
            "identifier": "014003729",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MENTAL HEALTH OUTPATIENT",
            "identifier": "103283EU",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MENTAL HEALTH OUTPATIENT",
            "identifier": "EM",
            "state": "NY"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MENTAL HEALTH OUTPATIENT",
            "identifier": "3109089",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Canandaigua, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 1, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.