Healthcare Provider Details

I. General information

NPI: 1528021334
Provider Name (Legal Business Name): MS. CHARLENE MOYER
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 LODER ST
SOUTH WAVERLY PA
18840-2611
US

IV. Provider business mailing address

356 LODER ST
SOUTH WAVERLY PA
18840-2611
US

V. Phone/Fax

Practice location:
  • Phone: 570-882-7414
  • Fax: 570-888-1204
Mailing address:
  • Phone: 570-882-7414
  • Fax: 570-888-1204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW0122161
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: