Basic Information
| Provider Information | |||||||||
| NPI: | 1306933023 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLEISSNER | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.A. PSYCHOLOGY | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1070 OLD NATIONAL PIKE | ||||||||
| Address2: | |||||||||
| City: | FREDERICKTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153332114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7246326801 | ||||||||
| FaxNumber: | 7246323198 | ||||||||
| Practice Location | |||||||||
| Address1: | 1152 WOOD ST | ||||||||
| Address2: | |||||||||
| City: | CALIFORNIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 154191260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249382099 | ||||||||
| FaxNumber: | 7249383221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 04/03/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1007288440090 | 05 | PA | MEDICAID | 328834A336347 | 01 | PA | VALUE BEHAVIORIAL HEALTH | OTHER |