Provider Demographics
NPI:1003172925
Name:SHARED SUPPORT, INC.
Entity Type:Organization
Organization Name:SHARED SUPPORT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FISCAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:E
Authorized Official - Last Name:PRATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-286-4982
Mailing Address - Street 1:218 BRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SUNBURY
Mailing Address - State:PA
Mailing Address - Zip Code:17801-1006
Mailing Address - Country:US
Mailing Address - Phone:570-286-4982
Mailing Address - Fax:570-286-4984
Practice Address - Street 1:218 BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:PA
Practice Address - Zip Code:17801-1006
Practice Address - Country:US
Practice Address - Phone:570-286-4982
Practice Address - Fax:570-286-4984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-04
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
164W00000X
PA329450251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251K00000XAgenciesPublic Health or Welfare
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101490123Medicaid