Basic Information
| Provider Information | |||||||||
| NPI: | 1770857401 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONEMAUGH HEALTH INITIATIVES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1086 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159054305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144108300 | ||||||||
| FaxNumber: | 8144108331 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 MAIN ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159011601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8145341095 | ||||||||
| FaxNumber: | 8145341625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2012 | ||||||||
| LastUpdateDate: | 03/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | LAMBERT | ||||||||
| AuthorizedOfficialFirstName: | ELAINE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8145341630 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 1007358110163 | 05 | PA | MEDICAID |