Provider Demographics
NPI:1518180199
Name:CAMERON ELK COUNTIES BEHAVIORAL AND DEVELOPMENTAL PROGRAMS
Entity Type:Organization
Organization Name:CAMERON ELK COUNTIES BEHAVIORAL AND DEVELOPMENTAL PROGRAMS
Other - Org Name:CAMERON ELK COUNTIES MH MR PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KROEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-772-8016
Mailing Address - Street 1:94 HOSPITAL ST
Mailing Address - Street 2:
Mailing Address - City:RIDGWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15853-1931
Mailing Address - Country:US
Mailing Address - Phone:814-772-8016
Mailing Address - Fax:814-772-8337
Practice Address - Street 1:94 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:RIDGWAY
Practice Address - State:PA
Practice Address - Zip Code:15853-1931
Practice Address - Country:US
Practice Address - Phone:814-772-8016
Practice Address - Fax:814-772-8337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA16270811171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007738680003Medicare ID - Type UnspecifiedMEDICAL ASSISTANCE