Healthcare Provider Details

I. General information

NPI: 1770636573
Provider Name (Legal Business Name): LYCOMING-CLINTON MHMR PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 EAST STREET THE SHARWELL BUILDING
WILLIAMSPORT PA
17701
US

IV. Provider business mailing address

200 EAST STREET THE SHARWELL BUILDING
WILLIAMSPORT PA
17701
US

V. Phone/Fax

Practice location:
  • Phone: 570-326-0924
  • Fax: 570-326-1348
Mailing address:
  • Phone: 570-326-0924
  • Fax: 570-326-1348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS004649L
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DOBORAH M DUFFY
Title or Position: ADMINISTRATOR
Credential:
Phone: 570-326-7895