1013982008 NPI number — DRUG AND ALCOHOL TREATMENT SERV

Table of content: SHIRA JORDAN LCSW 29372 (NPI 1568799286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013982008 NPI number — DRUG AND ALCOHOL TREATMENT SERV

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRUG AND ALCOHOL TREATMENT SERV
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013982008
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
116 N WASHINGTON AVE
Provider Second Line Business Mailing Address:
SUITE 3A
Provider Business Mailing Address City Name:
SCRANTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18503-1800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-961-1997
Provider Business Mailing Address Fax Number:
570-344-9632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
441 WYOMING AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCRANTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18503-1800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-344-3877
Provider Business Practice Location Address Fax Number:
570-344-1090
Provider Enumeration Date:
02/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCLAUGHLIN
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
570-344-3877

Provider Taxonomy Codes

  • Taxonomy code: 276400000X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 999022 . This is a "BCBS ID #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 90006 . This is a "GEISINGER HEALTH ID#" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 093511 . This is a "FPH ID #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007465840002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4544717 . This is a "AETNA ID#" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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