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NPI Code Detail

MEDICARE: MARK L. COLLISTER L.S.W.

MEDICARE: MARK L. COLLISTER L.S.W.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1104100000XSocial WorkerSW124379PA

General Provider Information

NPI Number : 1225078082
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARK L. COLLISTER L.S.W.
Provider Business Mailing Address
First Line : 10 CATHERINE DR
Second Line :
City : WILLIAMSPORT
State : PA
Zip : 17701-1292
Country : US
Telephone Number : 570-322-7873
Fax Number : 570-322-8026
Provider Business Practice Location Address
First Line : 435 W 4TH ST
Second Line :
City : WILLIAMSPORT
State : PA
Zip : 17701-6001
Country : US
Telephone Number : 570-322-7873
Fax Number : 570-322-8026
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/08/2006
Last Update Date : 07/08/2007

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