Healthcare Provider Details

I. General information

NPI: 1477689842
Provider Name (Legal Business Name): GOOD SHEPHERD CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1327 WYOMING AVE
SCRANTON PA
18509-2861
US

IV. Provider business mailing address

1327 WYOMING AVE
SCRANTON PA
18509-2861
US

V. Phone/Fax

Practice location:
  • Phone: 570-702-8360
  • Fax: 570-702-8623
Mailing address:
  • Phone: 570-702-8360
  • Fax: 570-702-8623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number000351062
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number000351062
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number000351062
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number000351062
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number000351062
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier1007283070003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: DR. JOHN ANTOGNOLI
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: ED.D.
Phone: 570-702-8360