MEDICARE: WILKES BARRE BEHAVIORAL HOSPITAL COMPANY LLC

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	320800000X	Mental Illness Community Based Residential Treatment Facility	221020	PA

General Provider Information

NPI Number	:	1649535139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILKES BARRE BEHAVIORAL HOSPITAL COMPANY LLC

Provider Business Mailing Address
First Line	:	562 WYOMING AVE
Second Line	:
City	:	KINGSTON
State	:	PA
Zip	:	18704-3721
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3504 BEAR CREEK BLVD
Second Line	:
City	:	BEAR CREEK TOWNSHIP
State	:	PA
Zip	:	18702-9760
Country	:	US
Telephone Number	:	570-718-0833
Fax Number	:	570-552-3907

Authorized Official
Title or Position	:	DIRECTOR/DELEGATED OFFICIAL
Name	:	PAULA LALOR
Credential	:
Telephone Number	:	629-215-3953

Provider Enumeration Date	:	07/10/2012
Last Update Date	:	04/30/2021

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