Healthcare Provider Details

I. General information

NPI: 1831849801
Provider Name (Legal Business Name): COLONIAL INTERMEDIATE UNIT 20
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 ROUTE 739
DINGMANS FERRY PA
18328-3406
US

IV. Provider business mailing address

6 DANFORTH DR
EASTON PA
18045-7820
US

V. Phone/Fax

Practice location:
  • Phone: 610-515-6439
  • Fax:
Mailing address:
  • Phone: 610-515-6439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEN KOSIBA
Title or Position: MEDICAL BILLER RESOLVE OUTPATIENT
Credential:
Phone: 610-515-6439