MEDICARE: PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES

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
1	315P00000X	Intellectual Disabilities Intermediate Care Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508849738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES

Provider Business Mailing Address
First Line	:	1000 US HIGHWAY 522
Second Line	:
City	:	SELINSGROVE
State	:	PA
Zip	:	17870-8707
Country	:	US
Telephone Number	:	570-372-5601
Fax Number	:	570-372-2500

Provider Business Practice Location Address
First Line	:	1000 US HIGHWAY 522
Second Line	:
City	:	SELINSGROVE
State	:	PA
Zip	:	17870-8707
Country	:	US
Telephone Number	:	570-372-5601
Fax Number	:	570-372-2500

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KATHY LIGHT
Credential	:
Telephone Number	:	717-772-2518

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	10/04/2021

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1447342084 — JOHN SLOYER M.A.
Practice Location Address:

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17870-8707

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17870-8707

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Directions to “PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES ” Practice Location

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