=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376638197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAINT VINCENT MEDICAL EDUCATION AND RESEARCH INSTITUTE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 11/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1910 SASSAFRAS ST SUITE 100
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16502-2716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-452-5555
-----------------------------------------------------
Fax | 814-452-7610
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3530 PEACH ST SUITE LL 1
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16508-2768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-860-5000
-----------------------------------------------------
Fax | 814-860-5050
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS DIRECTOR
-----------------------------------------------------
Name | PATTY BALLMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 814-452-5296
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------