Basic Information
| Provider Information | |||||||||
| NPI: | 1134539323 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIAKON CHILD, FAMILY & COMMUNITY MINISTRIES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIAKON FAMILY LIFE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 960 CENTURY DR | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170554374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177950330 | ||||||||
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| Practice Location | |||||||||
| Address1: | 571 MOUNTAIN RD | ||||||||
| Address2: | |||||||||
| City: | BOILING SPRINGS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170079520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177950330 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2014 | ||||||||
| LastUpdateDate: | 12/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | ROUSSEAU | ||||||||
| AuthorizedOfficialFirstName: | RITA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7177950330 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.