Healthcare Provider Details

I. General information

NPI: 1033541438
Provider Name (Legal Business Name): AUTISM DIAGNOSTIC EVALUATIONS RESOURCES SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2013
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 GRAYLYN CREST DR
NEW COLUMBIA PA
17856
US

IV. Provider business mailing address

276 GRAYLYN CREST DR
NEW COLUMBIA PA
17856-9418
US

V. Phone/Fax

Practice location:
  • Phone: 570-204-3717
  • Fax:
Mailing address:
  • Phone: 570-204-3717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1052542
License Number StatePA

VIII. Authorized Official

Name: MR. STEVE JAMES MCANNANEY
Title or Position: BEHAVIOR SPECIALIST
Credential: MSW
Phone: 570-204-3717