Healthcare Provider Details

I. General information

NPI: 1124310586
Provider Name (Legal Business Name): PEDIATRIC CARE SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 EISENHOWER BLVD PEDIATRIC CARE SPECIALISTS
JOHNSTOWN PA
15904
US

IV. Provider business mailing address

1322 EISENHOWER BLVD PEDIATRIC CARE SPECIALISTS
JOHNSTOWN PA
15904
US

V. Phone/Fax

Practice location:
  • Phone: 814-266-8840
  • Fax: 814-266-2176
Mailing address:
  • Phone: 814-266-8840
  • Fax: 814-266-2176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS016634
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCW015802
License Number StatePA

VIII. Authorized Official

Name: MS. PATRICIA LYNN AVRAMIS
Title or Position: PRIVACY OFFICER
Credential:
Phone: 814-266-8840