MEDICARE: THE OPEN DOOR OF INDIANA, PA

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	321050	PA

General Provider Information

NPI Number	:	1487710828
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE OPEN DOOR OF INDIANA, PA

Provider Business Mailing Address
First Line	:	665 PHILADELPHIA ST STE 202
Second Line	:
City	:	INDIANA
State	:	PA
Zip	:	15701-3941
Country	:	US
Telephone Number	:	724-465-2605
Fax Number	:	724-465-2610

Provider Business Practice Location Address
First Line	:	665 PHILADELPHIA ST STE 202
Second Line	:
City	:	INDIANA
State	:	PA
Zip	:	15701-3941
Country	:	US
Telephone Number	:	724-465-2605
Fax Number	:	724-465-2610

Authorized Official
Title or Position	:	CHIEF COMPLIANCE OFFICER
Name	:	JUDITH WOLFE
Credential	:
Telephone Number	:	724-465-2605

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	01/03/2023

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