Healthcare Provider Details

I. General information

NPI: 1114814019
Provider Name (Legal Business Name): COLONIAL INTERMEDIATE UNIT #20
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 MEMORIAL BLVD
TOBYHANNA PA
18466-7788
US

IV. Provider business mailing address

6 DANFORTH DR
EASTON PA
18045-7820
US

V. Phone/Fax

Practice location:
  • Phone: 610-515-6439
  • Fax: 484-291-4135
Mailing address:
  • Phone: 610-515-6439
  • Fax: 484-291-4135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: JEN KOSIBA
Title or Position: ASST MGMT FOR BILLING
Credential:
Phone: 610-515-6439