Healthcare Provider Details

I. General information

NPI: 1104970227
Provider Name (Legal Business Name): LYCOMING COUNTY CRIPPLED CHILDREN'S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 W EDWIN ST
WILLIAMSPORT PA
17701
US

IV. Provider business mailing address

625 W EDWIN ST
WILLIAMSPORT PA
17701
US

V. Phone/Fax

Practice location:
  • Phone: 570-326-0565
  • Fax: 570-329-2522
Mailing address:
  • Phone: 570-326-0565
  • Fax: 570-329-2522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPS005489L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS005489L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS005489L
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT000490E
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT002737L
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT016332L
License Number StatePA
# 7
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC006418L
License Number StatePA
# 8
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSL000825L
License Number StatePA
# 9
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSL002712L
License Number StatePA

VIII. Authorized Official

Name: MR. ANTHONY P. PERROTTA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 570-326-0565