Provider Demographics
NPI:1558795286
Name:THE DEVEREUX FOUNDATION
Entity Type:Organization
Organization Name:THE DEVEREUX FOUNDATION
Other - Org Name:PA CIDDS-LAURAVILLA
Other - Org Type:Other Name
Authorized Official - Title/Position:REIMBURSEMENT ANALYST
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DRY
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:610-542-3074
Mailing Address - Street 1:PO BOX 490A
Mailing Address - Street 2:
Mailing Address - City:VILLANOVA
Mailing Address - State:PA
Mailing Address - Zip Code:19085-0290
Mailing Address - Country:US
Mailing Address - Phone:610-542-3074
Mailing Address - Fax:610-542-3140
Practice Address - Street 1:390 E BOOT RD
Practice Address - Street 2:113 DEVEREUX CIRCLE
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-1222
Practice Address - Country:US
Practice Address - Phone:610-542-3074
Practice Address - Fax:610-542-3140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA135110320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000019130722Medicaid