Basic Information
| Provider Information | |||||||||
| NPI: | 1700384476 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAKON CHILD, FAMILY & COMMUNITY MINISTRIES | ||||||||
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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: | 1500 CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177012169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703227873 | ||||||||
| FaxNumber: | 5703228026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2018 | ||||||||
| LastUpdateDate: | 01/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF ADMINISTRATIVE OPS | ||||||||
| AuthorizedOfficialTelephone: | 5703227878 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIAKON LUTHERAN SOCIAL MINISTRIES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | 33160-0 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 33160-0 | 05 | PA | MEDICAID |