Basic Information
| Provider Information | |||||||||
| NPI: | 1467761924 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE DEVEREUX FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1041 W BRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIXVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194604342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109338110 | ||||||||
| FaxNumber: | 6109337451 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 GAY ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIXVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194604475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109338110 | ||||||||
| FaxNumber: | 6109337451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2010 | ||||||||
| LastUpdateDate: | 10/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | MCLAUGHLIN | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6109338110 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 102780 | PA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 100001913 | 05 | PA | MEDICAID |