Legal Provider Name:*DBA (If Applicable):Tax ID:Additional Tax ID (If Applicable):NPI(s):Additional NPI (If Applicable):License #:Organization Website:Service Location InformationPlease provide information about your service location(s).Primary Service Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Fax:Email : NPI:Tax ID:Do you have a secondary location?NoYesSecondary Service Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Fax:Email : NPI:Tax ID:If you have more than two service locations, please send a list of your locations, with address, contact info, and NPI/TaxID to frostj@southerntierconnect.orgOrganizational ContactsProvider Contact: Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Phone:Fax:Email: Credentialing Contact: Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Phone:Fax:Email: Service AreaAre you licensed to provide service in all NY counties?*YesNoI am/we are not licensed in any NY countiesPlease choose the NY counties where you are licensed to provide service: Albany County Allegany County Bronx County Broome County Cattaraugus County Cayuga County Chautauqua County Chemung County Chenango County Clinton County Columbia County Cortland County Delaware County Dutchess County Erie County Essex County Franklin County Fulton County Genesee County Greene County Hamilton County Herkimer County Jefferson County Kings County (Brooklyn) Lewis County Livingston County Madison County Monroe County Montgomery County Nassau County New York County (Manhattan) Niagara County Oneida County Onondaga County Ontario County Orange County Orleans County Oswego County Otsego County Putnam County Queens County Rensselaer County Richmond County (Staten Island) Rockland County Saint Lawrence County Saratoga County Schenectady County Schoharie County Schuyler County Seneca County Steuben County Suffolk County Sullivan County Tioga County Tompkins County Ulster County Warren County Washington County Wayne County Westchester County Wyoming County Yates County Services ProvidedPlease check all services your organization provides: Free Standing Clinic I/DD Service Provider Inpatient Hospital Medical Care Providers Outpatient Hospital Free Standing Clinic Services Provided: General FQHC’s Article 16 - OPWDD Article 28 - DOH Article 31 - OMH Article 32 - OASAS Audiology Chronic Disease Self-Mgmt Day Treatment Dental Enrollee Education Services Medication Managment Nutrition Optometry Partial Hospitalization Podiatry Psychiatric Therapy Other Please select all services your free standing clinic providesI/DD Services Provided: Adaptive Services - Assistive Tech (CFCO) Assistive Technology Behavioral Health Rehabilitation Services ACT Behavioral Health Rehabilitation Services OMH Behavioral Health Rehabilitation Services PROS Community Habilitation Community Transitional Services Day Habilitation Durable Medical Equipment/ Medical Supplies Environmental Modification Family Education and Training Fiscal Intermediary HCBS Care Management Home Delivered/Congregate Meals Home Health Home Health Care (AIDE) Homemaker/Housekeeper Individual Directed Goods and Services Intensive Behavioral Support (IBP) Live-in Caregiver LTSS: Adult Day Health LTSS: Personal Care Moving Assitance Nursing Pathway to Employment Personal Care/Consumer Directed Personal Assistance Program (CDPAS) Personal Emergency Response (PERS) Prevocational Habilitation, Community-Based Prevocational Habilitation, Site-Based Regional START Team Crisis Prevention Regional START Team Response Services Residential Habilitation Respite Services to Support Self Direction Skilled Nursing Facility Support Brokerage Supported Employment Habilitation (SEMP) Supportive Health Services School-Based Early Intervention Transportation - Non-emergency, medical Transportation - Non-emergency, social Vehicle Modification Other Please select all I/DD services your organization providesInpatient Hospital Services Provided: Behavioral Health Dental General Psychiatric Residential Treatment Facility Substance Abuse Services Other Please select all services your inpatient hospital providesMedical Care Services Provided: Ambulatory Care Audiology Dental Optometry Podiatry Preventative Care Primary Care Rehabilitation Therapy Wellness Care Other Specialty/Specialties Please select all medical care services you provideAdditional Specialist Services Provided:Outpatient Hospital Services Provided: Audiology Behavioral Health Day Treatment Dental Emergency Room General Laboratory Nutrition Optometry Partial Hospitalization Podiatry Psychiatric Rehabilitation Therapy Providers Other Please select all services your outpatient hospital provides