Basic Information
| Provider Information | |||||||||
| NPI: | 1770750481 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAKON LUTHERAN SOCIAL MINISTRIES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 435 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177016001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 960 CENTURY DR | ||||||||
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| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170554374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177950330 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2008 | ||||||||
| LastUpdateDate: | 05/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | ROUSSEAU | ||||||||
| AuthorizedOfficialFirstName: | RITA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7177950330 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIAKON LUTHERAN SOCIAL MINISTRIES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1007777400061 | 05 | PA | MEDICAID |