Provider Demographics
NPI:1073940177
Name:DEVEREUX CIDDS DONOVAN
Entity Type:Organization
Organization Name:DEVEREUX CIDDS DONOVAN
Other - Org Name:DEVEREUX FOUNDATION
Other - Org Type:Other Name
Authorized Official - Title/Position:NATIONAL DIRECTOR OF ACCOUNTS RECEI
Authorized Official - Prefix:MS
Authorized Official - First Name:FRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-542-3084
Mailing Address - Street 1:390 E BOOT RD
Mailing Address - Street 2:102 GENUARDI CIRCLE
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-1222
Mailing Address - Country:US
Mailing Address - Phone:610-431-8100
Mailing Address - Fax:
Practice Address - Street 1:390 E BOOT RD
Practice Address - Street 2:102 GENUARDI CIRCLE
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-1222
Practice Address - Country:US
Practice Address - Phone:610-431-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEVEREUX FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA132890322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000019130621Medicaid
PA1000019130725Medicaid