Basic Information
| Provider Information | |||||||||
| NPI: | 1609257930 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEVEREUX | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 85 OLD EAGLE RD | ||||||||
| Address2: | |||||||||
| City: | STRAFFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190872556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106884849 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 85 OLD EAGLE RD | ||||||||
| Address2: | |||||||||
| City: | STRAFFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190872556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106884849 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2015 | ||||||||
| LastUpdateDate: | 06/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | GOINS | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | BSC/MT | ||||||||
| AuthorizedOfficialTelephone: | 6106884849 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MSW LSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 44SL04976400 | NJ | Y | Agencies | Case Management |
No ID Information.