Provider Demographics
NPI:1124209440
Name:TREHAB DRUG AND ALCOHOL OUTPATIENT PROGRAM
Entity Type:Organization
Organization Name:TREHAB DRUG AND ALCOHOL OUTPATIENT PROGRAM
Other - Org Name:TREHAB
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-278-5227
Mailing Address - Street 1:36 PUBLIC AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MONTROSE
Mailing Address - State:PA
Mailing Address - Zip Code:18801-1220
Mailing Address - Country:US
Mailing Address - Phone:570-278-3338
Mailing Address - Fax:
Practice Address - Street 1:36 PUBLIC AVE
Practice Address - Street 2:BOX 366
Practice Address - City:MONTROSE
Practice Address - State:PA
Practice Address - Zip Code:18801-1220
Practice Address - Country:US
Practice Address - Phone:570-278-3338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAH6526601251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100-730-1450005OtherMEDICAL ASSISTANCE
PA100-730-1450007OtherMEDICAL ASSISTANCE
PA100-730-1450006OtherMEDICAL ASSISTANCE