Provider Demographics
NPI:1255480174
Name:PERSEUS HOUSE, INC
Entity Type:Organization
Organization Name:PERSEUS HOUSE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:AMENDOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-480-5956
Mailing Address - Street 1:1511 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-2104
Mailing Address - Country:US
Mailing Address - Phone:814-480-5911
Mailing Address - Fax:814-454-8670
Practice Address - Street 1:1510 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-2220
Practice Address - Country:US
Practice Address - Phone:814-480-5905
Practice Address - Fax:814-456-4229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA407390251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA407390Medicaid