=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699847392
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINEBROOK FAMILY ANSWERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 11/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 NORTHAMPTON ST STE 201
-----------------------------------------------------
City | EASTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18042-4152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-559-8151
-----------------------------------------------------
Fax | 610-559-9056
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 402 N FULTON ST
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18102-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-432-3919
-----------------------------------------------------
Fax | 610-432-5174
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | LESLIE TENBROECK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-774-1434
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number | 204540
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------