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General NPI Number Information
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NPI Number | 1639202534
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Entity Type | Organization
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Legal Business Name | FAYETTE COUNTY MENTAL HEALTH MENTAL RETARDATION PROGRAM
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Dates
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Enumeration Date | 03/13/2007
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Last Update Date | 01/03/2024
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Provider Practice Location Address
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Address Line | 215 JACOB MURPHY LN
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City | UNIONTOWN
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State | PA
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Zip | 15401-2777
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Country | US
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Telephone | 724-430-1370
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Fax | 724-430-1386
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Provider Business Mailing Address
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Address Line | 215 JACOB MURPHY LN
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City | UNIONTOWN
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State | PA
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Zip | 15401-2777
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Country | US
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Telephone | 724-430-1370
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Fax | 724-430-1386
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Authorized Official
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Title or Position | ADMINISTRATOR CEO
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Name | MR. DAVID RIDER
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Credential | M.A., M.DIV.
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Telephone | 724-430-1370
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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