Healthcare Provider Details

I. General information

NPI: 1689025389
Provider Name (Legal Business Name): CENTRE PROFESSIONAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S ALLEN ST STE 216
STATE COLLEGE PA
16801-4849
US

IV. Provider business mailing address

PO BOX 1120
LEMONT PA
16851-1120
US

V. Phone/Fax

Practice location:
  • Phone: 814-689-9744
  • Fax: 888-981-8069
Mailing address:
  • Phone: 814-689-9744
  • Fax: 888-981-8069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberMD056013L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD056013L
License Number StatePA

VIII. Authorized Official

Name: DR. TIMOTHY DERSTINE
Title or Position: OWNER
Credential: MD
Phone: 814-689-9744