Provider Demographics
NPI:1548384225
Name:DEVEREUX KANNER
Entity Type:Organization
Organization Name:DEVEREUX KANNER
Other - Org Name:KANNER ANN VILLA
Other - Org Type:Other Name
Authorized Official - Title/Position:NATIONAL DIRECTOR, AR
Authorized Official - Prefix:
Authorized Official - First Name:FRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-542-3084
Mailing Address - Street 1:2012 RENAISSANCE BLVD
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-2786
Mailing Address - Country:US
Mailing Address - Phone:610-542-3084
Mailing Address - Fax:610-542-3191
Practice Address - Street 1:390 E BOOT RD
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-1222
Practice Address - Country:US
Practice Address - Phone:610-431-8100
Practice Address - Fax:610-431-3155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA112070320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0010502Medicaid