Provider Demographics
NPI:1003259672
Name:CENTRAL PENNSYLVANIA SUPPORTIVE SERVICES, INC. (CPSS)
Entity Type:Organization
Organization Name:CENTRAL PENNSYLVANIA SUPPORTIVE SERVICES, INC. (CPSS)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LETA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:CPRP
Authorized Official - Phone:717-901-5099
Mailing Address - Street 1:PO BOX 62126
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17106-2126
Mailing Address - Country:US
Mailing Address - Phone:717-901-5099
Mailing Address - Fax:717-901-0388
Practice Address - Street 1:1820 LINGLESTOWN RD
Practice Address - Street 2:SUITE SE-L
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-3339
Practice Address - Country:US
Practice Address - Phone:717-901-5099
Practice Address - Fax:717-901-0388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-12
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA159341251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101858549Medicaid