Basic Information
Provider Information | |||||||||
NPI: | 1477582070 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DIAKON LUTHERAN SOCIAL MINISTRIES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DIAKON FAMILY LIFE SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 435 W 4TH ST | ||||||||
Address2: |   | ||||||||
City: | WILLIAMSPORT | ||||||||
State: | PA | ||||||||
PostalCode: | 177016001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5703227873 | ||||||||
FaxNumber: | 5703228026 | ||||||||
Practice Location | |||||||||
Address1: | 201 W LOUTHER ST | ||||||||
Address2: |   | ||||||||
City: | CARLISLE | ||||||||
State: | PA | ||||||||
PostalCode: | 170132813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7177950330 | ||||||||
FaxNumber: | 7177950407 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2006 | ||||||||
LastUpdateDate: | 11/07/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROUSSEAU | ||||||||
AuthorizedOfficialFirstName: | RITA | ||||||||
AuthorizedOfficialMiddleName: | A. | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR COS | ||||||||
AuthorizedOfficialTelephone: | 7177950368 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 02319100 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1526223 | 01 | PA | PA BLUE SHIELD - CRNP | OTHER | 1007777400044 | 05 | PA |   | MEDICAID | 301029 | 01 | PA | VALUEOPTIONS | OTHER |