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General NPI Number Information
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NPI Number | 1932112174
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Entity Type | Organization
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Legal Business Name | AVIS BEHAVIORAL HEALTH
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Dates
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Enumeration Date | 08/15/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 302 WEST CENTRAL AVE.
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City | AVIS
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State | PA
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Zip | 17721-1070
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Country | US
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Telephone | 570-753-3620
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Fax | 570-753-3620
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Provider Business Mailing Address
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Address Line | 302 WEST CENTRAL AVE. PO BOX 1070
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City | AVIS
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State | PA
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Zip | 17721-1070
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Country | US
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Telephone | 570-753-3620
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Fax | 570-753-3620
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Authorized Official
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Title or Position | PRESIDENT OWNER PSYCHOTHERAPIST
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Name | MISS PATRICIA ANN DERSHEM
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Credential | MSS LCSW
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Telephone | 570-753-3620
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CW008439L
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License Number State | PA
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