Healthcare Provider Details

I. General information

NPI: 1518187699
Provider Name (Legal Business Name): CENTRE COUNTY MH ID EI DA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 E COLLEGE AVE SUITE 1200
STATE COLLEGE PA
16801-7569
US

IV. Provider business mailing address

3500 E COLLEGE AVE SUITE 1200
STATE COLLEGE PA
16801-7569
US

V. Phone/Fax

Practice location:
  • Phone: 814-355-6782
  • Fax: 814-355-6985
Mailing address:
  • Phone: 814-355-6782
  • Fax: 814-355-6985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1007296630024
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier1007296630023
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: THOMAS J MCDERMOTT
Title or Position: ADMINISTRATOR
Credential:
Phone: 814-355-6782