Provider Demographics
NPI:1174686026
Name:COLONIAL HOUSE, INC
Entity Type:Organization
Organization Name:COLONIAL HOUSE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AURORA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC, CAADC
Authorized Official - Phone:717-792-1366
Mailing Address - Street 1:1300 WOODBERRY ROAD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17408-5840
Mailing Address - Country:US
Mailing Address - Phone:717-792-1366
Mailing Address - Fax:717-792-9910
Practice Address - Street 1:1300 WOODBERRY ROAD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17408-5840
Practice Address - Country:US
Practice Address - Phone:717-792-1366
Practice Address - Fax:717-792-9910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA677065261QR0405X
PA671099324500000X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00016277720001Medicaid