Healthcare Provider Details

I. General information

NPI: 1639153968
Provider Name (Legal Business Name): NORTHUMBERLAND COUNTY MENTAL HEALTH MENTAL RETARDATION PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 N CENTER ST BLDG A
SUNBURY PA
17801-2205
US

IV. Provider business mailing address

217 N CENTER ST BLDG A
SUNBURY PA
17801-2205
US

V. Phone/Fax

Practice location:
  • Phone: 570-495-2212
  • Fax: 570-988-4444
Mailing address:
  • Phone: 570-495-2212
  • Fax: 570-988-4444

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
Identifier1007378070002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MRS. JUDITH C DAVIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 570-495-2002