Basic Information
| Provider Information | |||||||||
| NPI: | 1427292622 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILKES-BARRE BEHAVIORAL HOSPITAL COMPANY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 MERIDIAN BLVD | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370676325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154657000 | ||||||||
| FaxNumber: | 6156286877 | ||||||||
| Practice Location | |||||||||
| Address1: | 562 WYOMING AVE | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187043721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705523865 | ||||||||
| FaxNumber: | 5705523875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2009 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 8778929815 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 102288577-0005 | 05 | PA | MEDICAID |