Healthcare Provider Details

I. General information

NPI: 1669608477
Provider Name (Legal Business Name): WILKES BARRE BEHAVIORAL HOSPITAL COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 BRIDGE ST
TUNKHANNOCK PA
18657-1303
US

IV. Provider business mailing address

562 WYOMING AVE
KINGSTON PA
18704-3721
US

V. Phone/Fax

Practice location:
  • Phone: 570-836-3118
  • Fax: 570-836-1117
Mailing address:
  • Phone: 570-552-3700
  • Fax: 570-552-3733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number222480
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: PAULA LALOR
Title or Position: DIRECTOR/DELEGATED OFFICIAL
Credential:
Phone: 615-925-4565