Provider Demographics
NPI:1578543054
Name:SUSQUEHANNA VALLEY PROFESSIONAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:SUSQUEHANNA VALLEY PROFESSIONAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:HANS
Authorized Official - Last Name:DERSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-867-9755
Mailing Address - Street 1:320 ROLLING RIDGE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-7641
Mailing Address - Country:US
Mailing Address - Phone:814-867-0670
Mailing Address - Fax:814-867-7616
Practice Address - Street 1:320 ROLLING RIDGE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7641
Practice Address - Country:US
Practice Address - Phone:814-867-0670
Practice Address - Fax:814-867-7616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02892000OtherCAPITAL BLUE CROSS
PA02892000OtherCAPITAL BLUE CROSS