Organization
UPSTATE KETAMINE CARE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JEFFREY C LEATHERSICH (PRACTICE ADMINISTRATOR)
(585) 673-2319
Entity
Organization
Contact information
Practice address
3300 MONROE AVE STE 319, ROCHESTER, NY 14618-4617
(585) 673-2319
Mailing address
3300 MONROE AVE STE 319, ROCHESTER, NY 14618-4617
(585) 673-2319
Taxonomy
Speciality
Code
Description
License number
State
364SP0808X
Psychiatric/Mental Health Clinical Nurse Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
03426666
—
NY
Enumeration date
11/13/2019
Last updated
11/13/2019
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