Healthcare Provider Details

I. General information

NPI: 1427881689
Provider Name (Legal Business Name): STEPHEN BRUSH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 MOOSIC RD
OLD FORGE PA
18518-2082
US

IV. Provider business mailing address

1251 WYOMING AVE
EXETER PA
18643-1434
US

V. Phone/Fax

Practice location:
  • Phone: 570-342-8434
  • Fax: 570-299-2521
Mailing address:
  • Phone: 570-342-8434
  • Fax: 570-299-2521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW137182
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: