Basic Information
| Provider Information | |||||||||
| NPI: | 1407892615 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAKON LUTHERAN SOCIAL MINISTRIES | ||||||||
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| OtherOrganizationName: | 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: | 1600 FOWLER AVE | ||||||||
| Address2: | |||||||||
| City: | BERWICK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 186031423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703227873 | ||||||||
| FaxNumber: | 5703228026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROUSSEAU | ||||||||
| AuthorizedOfficialFirstName: | RITA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR COS | ||||||||
| AuthorizedOfficialTelephone: | 7177950368 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 356240 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 02319100 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 301029 | 01 | PA | VALUEOPTIONS | OTHER | 1007777400038 | 05 | PA | MEDICAID |