Healthcare Provider Details

I. General information

NPI: 1497167167
Provider Name (Legal Business Name): BERKS THERAPEUTIC ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 N PARK RD SUITE 101
WYOMISSING PA
19610-1342
US

IV. Provider business mailing address

845 N PARK RD SUITE 101
WYOMISSING PA
19610-1342
US

V. Phone/Fax

Practice location:
  • Phone: 610-334-8131
  • Fax:
Mailing address:
  • Phone: 610-334-8131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMD426302
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPC002868
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD426302
License Number StatePA

VIII. Authorized Official

Name: DR. SCOT MASON DEPUE
Title or Position: CEO
Credential: M.D.
Phone: 484-769-7626