Provider Demographics
NPI:1114337391
Name:DIAKON CHILD, FAMILY & COMMUNITY MINISTRIES
Entity Type:Organization
Organization Name:DIAKON CHILD, FAMILY & COMMUNITY MINISTRIES
Other - Org Name:DIAKON FAMILY LIFE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-795-0368
Mailing Address - Street 1:435 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-6001
Mailing Address - Country:US
Mailing Address - Phone:570-322-7873
Mailing Address - Fax:570-322-8026
Practice Address - Street 1:435 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-6001
Practice Address - Country:US
Practice Address - Phone:570-322-7873
Practice Address - Fax:570-322-8026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-28
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA301029OtherVALUEOPTIONS
PA1526223OtherPA BLUE SHIELD - CRNP
PA803181OtherFIRST PRIORITY HEALTH
PA080465OtherFPH - PSYCHOLOGIST
PA1443618OtherPA BLUE SHIELD - PSYCHOLO
PA1808012OtherPA BS - LCSW FEP ONLY
PA716009OtherPA BLUE SHIELD - MD/DO
PA02319100OtherCAPITAL BLUE CROSS
PA1007777400006Medicaid
PA803181OtherFIRST PRIORITY HEALTH
PA1007777400036Medicaid