=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336050632
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERAKEY PENNSYLVANIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2026
-----------------------------------------------------
Last Update Date | 09/15/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8932 JEWELLA AVE
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71118-2117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-219-4167
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8932 JEWELLA AVE
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71118-2117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DERRICK YACOVELLI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-260-4601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------