Basic Information
| Provider Information | |||||||||
| NPI: | 1376923896 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH PENN COMPREHENSIVE HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LAUREL BEHAVIORAL HEALTH OUTPATIENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 W WELLSBORO ST | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 169331411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706621945 | ||||||||
| FaxNumber: | 5706622390 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 EAST AVE | ||||||||
| Address2: | |||||||||
| City: | WELLSBORO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 169011737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707230620 | ||||||||
| FaxNumber: | 5707240675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2015 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VANZILE | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5706621945 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTH PENN COMPREHENSIVE HEALTH SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 391056 | 01 | PA | MEDICARE PART A | OTHER | 103562 | 01 | PA | MEDICARE PART B | OTHER | 1000011720142 | 05 | PA | MEDICAID |