Basic Information
| Provider Information | |||||||||
| NPI: | 1427468578 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIAKON CHILD, FAMILY & COMMUNITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIAKON 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: | 300 WEST HIGH STREET | ||||||||
| Address2: | CO NEW BLOOMFIELD ELEMENTARY SCHOOL | ||||||||
| City: | NEW BLOOMFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707950330 | ||||||||
| FaxNumber: | 5707950407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2014 | ||||||||
| LastUpdateDate: | 05/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | ROUSSEAU | ||||||||
| AuthorizedOfficialFirstName: | RITA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7177950368 | ||||||||
| 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.