Basic Information
| Provider Information | |||||||||
| NPI: | 1669882700 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIAKON CHILD, FAMILY & COMMUNITY MINISTRIES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DIAKON FAMILY LIFE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 960 CENTURY DR | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170554374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177950330 | ||||||||
| FaxNumber: | 7177950407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2014 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF ADM. OPS | ||||||||
| AuthorizedOfficialTelephone: | 5703227873 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 716009 | 01 | PA | PA BLUE SHIELD - MD/DO | OTHER | 02319100 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 1443618 | 01 | PA | PA BLUE SHIELD - PSYCHOLO | OTHER | 1526223 | 01 | PA | PA BLUE SHIELD - CRNP | OTHER | 1808012 | 01 | PA | PA BLUE SHIELD FEP - LCSW | OTHER | 301029 | 01 | PA | VALUEOPTIONS | OTHER |