=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225832306
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLONIAL INTERMEDIATE UNIT #20
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2025
-----------------------------------------------------
Last Update Date | 04/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 180 PANTHER LN
-----------------------------------------------------
City | POCONO SUMMIT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18346-7724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-515-6439
-----------------------------------------------------
Fax | 484-291-4135
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 DANFORTH DR
-----------------------------------------------------
City | EASTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18045-7820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-252-5550
-----------------------------------------------------
Fax | 610-252-5740
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASST MGMT TO MEDICAL BILLING
-----------------------------------------------------
Name | JEN KOSIBA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-515-6439
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------