Healthcare Provider Details

I. General information

NPI: 1306960091
Provider Name (Legal Business Name): DEVEREUX KANNER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 E BOOT RD 101 GENUARDI CIRCLE
WEST CHESTER PA
19380-1222
US

IV. Provider business mailing address

2012 RENAISSANCE BLVD
KING OF PRUSSIA PA
19406-2786
US

V. Phone/Fax

Practice location:
  • Phone: 610-431-8100
  • Fax: 610-431-3155
Mailing address:
  • Phone: 610-542-3084
  • Fax: 610-542-3191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number112050
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number132880
License Number StatePA

VIII. Authorized Official

Name: FRAN WAGNER
Title or Position: NATIONAL DIRECTOR, AR
Credential:
Phone: 610-542-3084