Basic Information
| Provider Information | |||||||||
| NPI: | 1467821207 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIAKON CHILD, FAMILY AND COMMUNITY MINISTRIES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIAKON FAMILY LIFE SERVICE | ||||||||
| 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: | 241 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | MONTOURSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177542283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704337060 | ||||||||
| FaxNumber: | 5705677184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2015 | ||||||||
| LastUpdateDate: | 09/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | HABECKER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT/COO/FCO | ||||||||
| AuthorizedOfficialTelephone: | 6106821262 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIAKON LUTHERAN SOCIAL MINISTRIES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 331600 | PA | Y | Agencies | Community/Behavioral Health |
No ID Information.