Provider Demographics
NPI:1528229804
Name:MARTHA LLOYD CRF COPPERTREE
Entity Type:Organization
Organization Name:MARTHA LLOYD CRF COPPERTREE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-297-2185
Mailing Address - Street 1:190 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:PA
Mailing Address - Zip Code:16947-1131
Mailing Address - Country:US
Mailing Address - Phone:570-297-2185
Mailing Address - Fax:570-297-1019
Practice Address - Street 1:20 BALLARD ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:PA
Practice Address - Zip Code:16947-1002
Practice Address - Country:US
Practice Address - Phone:570-297-2185
Practice Address - Fax:570-297-1019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA202850320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015544810023Medicaid