Healthcare Provider Details

I. General information

NPI: 1770721359
Provider Name (Legal Business Name): JOSEPH DIVACK LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2009
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 MAY AVE
MC KEES ROCKS PA
15136-3676
US

IV. Provider business mailing address

19 MAY AVE
MC KEES ROCKS PA
15136-3676
US

V. Phone/Fax

Practice location:
  • Phone: 412-331-7712
  • Fax: 412-331-0982
Mailing address:
  • Phone: 412-331-7712
  • Fax: 412-331-0982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW002485E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: