Healthcare Provider Details

I. General information

NPI: 1134308570
Provider Name (Legal Business Name): CENTER FOR DEVELOPMENTAL DISABILITIES OF PIKE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2007
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 POCONO DRVIE SUITE 2
MILFORD PA
18337-9408
US

IV. Provider business mailing address

101 POCONO DR SUITE 2
MILFORD PA
18337-9408
US

V. Phone/Fax

Practice location:
  • Phone: 570-296-3992
  • Fax: 570-296-4919
Mailing address:
  • Phone: 570-296-3992
  • Fax: 570-296-4919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number243890
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. JO ANN DONNELLY
Title or Position: DIRECTOR
Credential:
Phone: 570-296-3992