1538372115 NPI number — LYCOMING-CLINTON JOINDER BOARD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538372115 NPI number — LYCOMING-CLINTON JOINDER BOARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LYCOMING-CLINTON JOINDER BOARD
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:
LYCOMING-CLINTON MHMR PROGRAM
Provider Other Organization Name Type Code:
5
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:
1538372115
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 EAST STREET
Provider Second Line Business Mailing Address:
THE SHARWELL BUILDING
Provider Business Mailing Address City Name:
WILLIAMSPORT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-326-0924
Provider Business Mailing Address Fax Number:
570-326-1348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 EAST STREET
Provider Second Line Business Practice Location Address:
THE SHARWELL BUILDING
Provider Business Practice Location Address City Name:
WILLIAMSPORT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-326-0924
Provider Business Practice Location Address Fax Number:
570-326-1348
Provider Enumeration Date:
05/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DIDOMENICO
Authorized Official First Name:
ELLEN
Authorized Official Middle Name:
Authorized Official Title or Position:
HUMAN SERVICES DIRECTOR
Authorized Official Telephone Number:
570-323-6467

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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