Provider Demographics
NPI:1053476879
Name:CLEARFIELD-JEFFERSON MHMR PROGRAM
Entity Type:Organization
Organization Name:CLEARFIELD-JEFFERSON MHMR PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:COLETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUSHAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-265-1060
Mailing Address - Street 1:1200 WOOD ST STE U110
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15824-2118
Mailing Address - Country:US
Mailing Address - Phone:814-265-1060
Mailing Address - Fax:814-265-1049
Practice Address - Street 1:1200 WOOD ST STE U110
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:PA
Practice Address - Zip Code:15824-2118
Practice Address - Country:US
Practice Address - Phone:814-265-1060
Practice Address - Fax:814-265-1049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007332450006Medicaid