Basic Information
| Provider Information | |||||||||
| NPI: | 1871537118 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIAKON LUTHERAN SOCIAL MINISTRIES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIAKON FAMILY LIFE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 435 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177016001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703227873 | ||||||||
| FaxNumber: | 5703228026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 11/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | ROUSSEAU | ||||||||
| AuthorizedOfficialFirstName: | RITA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR COS | ||||||||
| AuthorizedOfficialTelephone: | 7177950368 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 301029 | 01 | PA | VALUEOPTIONS | OTHER | 1007777400036 | 05 | PA | MEDICAID | 1808012 | 01 | PA | PA BS - LCSW FEP ONLY | OTHER | 02319100 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 080465 | 01 | PA | FPH - PSYCHOLOGIST | OTHER | 1443618 | 01 | PA | PA BLUE SHIELD - PSYCHOLO | OTHER | 1007777400006 | 05 | PA | MEDICAID | 1526223 | 01 | PA | PA BLUE SHIELD - CRNP | OTHER | 716009 | 01 | PA | PA BLUE SHIELD - MD/DO | OTHER | 803181 | 01 | PW | FIRST PRIORITY HEALTH | OTHER |