Basic Information
| Provider Information | |||||||||
| NPI: | 1518435114 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY SERVICES OF DEVEREUX | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 DEERFIELD LN STE 100 | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193552100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109338110 | ||||||||
| FaxNumber: | 6109337451 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 DEERFIELD LN STE 100 | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193552100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109338110 | ||||||||
| FaxNumber: | 6109337451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2018 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCLAUGHLIN | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6104221463 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEVEREUX FOUNDATION | ||||||||
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| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1000019130441 | 05 | PA | MEDICAID |