Healthcare Provider Details

I. General information

NPI: 1578543054
Provider Name (Legal Business Name): SUSQUEHANNA VALLEY PROFESSIONAL ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 ROLLING RIDGE DR SUITE 100
STATE COLLEGE PA
16801-7641
US

IV. Provider business mailing address

320 ROLLING RIDGE DR SUITE 100
STATE COLLEGE PA
16801-7641
US

V. Phone/Fax

Practice location:
  • Phone: 814-867-0670
  • Fax: 814-867-7616
Mailing address:
  • Phone: 814-867-0670
  • Fax: 814-867-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier02892000
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCAPITAL BLUE CROSS

VIII. Authorized Official

Name: TIMOTHY HANS DERSTINE
Title or Position: MANAGING DIRECTOR
Credential: M.D.
Phone: 814-867-9755