Healthcare Provider Details

I. General information

NPI: 1558969741
Provider Name (Legal Business Name): CENTERVILLE CLINICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 10/12/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CENTERVILLE CLINICS-INTENSIVE BEHAVIORAL HEALTH SERVICE 37 HIGHLAND AVENUE
WASHINGTON PA
15301-4062
US

IV. Provider business mailing address

CENTERVILLE CLINICS INC 1070 OLD NATIONAL PIKE ROAD
FREDERICKTOWN PA
15333-2114
US

V. Phone/Fax

Practice location:
  • Phone: 724-223-1067
  • Fax: 724-223-1088
Mailing address:
  • Phone: 724-632-6801
  • Fax: 724-632-6312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. BARRY R NICCOLAI
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 724-635-6801