Basic Information
| Provider Information | |||||||||
| NPI: | 1083770838 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAKON LUTHERAN SOCIAL MINISTRIES | ||||||||
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| OtherOrganizationName: | DIAKON FAMILY LIFE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 435 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177016001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703227873 | ||||||||
| FaxNumber: | 5703228026 | ||||||||
| Practice Location | |||||||||
| Address1: | CO NEW BLOOMFIELD ELEMENTARY SCHOOL | ||||||||
| Address2: | 300 WEST HIGH STREET | ||||||||
| City: | NEW BLOOMFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707950330 | ||||||||
| FaxNumber: | 5707950407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 10/24/2007 | ||||||||
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| AuthorizedOfficialLastName: | ROUSSEAU | ||||||||
| AuthorizedOfficialFirstName: | RITA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR OF COS | ||||||||
| AuthorizedOfficialTelephone: | 7177950368 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1007777400042 | 05 | PA | MEDICAID |