Provider Demographics
NPI:1518187699
Name:CENTRE COUNTY MH ID EI DA
Entity Type:Organization
Organization Name:CENTRE COUNTY MH ID EI DA
Other - Org Name:DA CASEMANAGEMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-355-6782
Mailing Address - Street 1:3500 E COLLEGE AVE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-7569
Mailing Address - Country:US
Mailing Address - Phone:814-355-6782
Mailing Address - Fax:814-355-6985
Practice Address - Street 1:3500 E COLLEGE AVE
Practice Address - Street 2:SUITE 1200
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7569
Practice Address - Country:US
Practice Address - Phone:814-355-6782
Practice Address - Fax:814-355-6985
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF CENTRE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-30
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007296630024Medicaid
PA1007296630023Medicaid