Basic Information
| Provider Information | |||||||||
| NPI: | 1457562977 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE DEVEREUX FOUNDATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY SERVICES OF DEVEREUX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 30 S VALLEY RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PAOLI | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193011450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109338110 | ||||||||
| FaxNumber: | 6109337451 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 S VALLEY RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PAOLI | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193011450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109338110 | ||||||||
| FaxNumber: | 6109337451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCLAUGHLIN | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6109338110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | PA | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 100001913 0326 | 05 | PA | MEDICAID |