MEDICARE: CARBON-MONROE-PIKE MH/MR PROGRAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1275724163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARBON-MONROE-PIKE MH/MR PROGRAM

Provider Business Mailing Address
First Line	:	724 PHILLIPS ST
Second Line	:	SUITE 202
City	:	STROUDSBURG
State	:	PA
Zip	:	18360-2242
Country	:	US
Telephone Number	:	570-420-1900
Fax Number	:	570-517-5422

Provider Business Practice Location Address
First Line	:	146 NORTH ST
Second Line	:	SUITE 3
City	:	LEHIGHTON
State	:	PA
Zip	:	18235-1546
Country	:	US
Telephone Number	:	570-420-1900
Fax Number	:	570-517-5422

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	SHEILA THEODOROU
Credential	:
Telephone Number	:	570-420-1900

Provider Enumeration Date	:	08/06/2007
Last Update Date	:	08/06/2007

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