Provider Demographics
NPI:1497167167
Name:BERKS THERAPEUTIC ALLIANCE
Entity Type:Organization
Organization Name:BERKS THERAPEUTIC ALLIANCE
Other - Org Name:KEYSTONE BLUE HEN PC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:MASON
Authorized Official - Last Name:DEPUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:484-769-7626
Mailing Address - Street 1:845 N PARK RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-1342
Mailing Address - Country:US
Mailing Address - Phone:610-334-8131
Mailing Address - Fax:
Practice Address - Street 1:845 N PARK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1342
Practice Address - Country:US
Practice Address - Phone:610-334-8131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD426302101YA0400X, 207P00000X
PAPC002868103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF52533Medicare UPIN