Provider Demographics
NPI:1619947348
Name:CARBON - MONROE - PIKE DRUG & ALCOHOL COMMISSION, INC
Entity Type:Organization
Organization Name:CARBON - MONROE - PIKE DRUG & ALCOHOL COMMISSION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:BS CADC
Authorized Official - Phone:570-421-1960
Mailing Address - Street 1:724 PHILLIPS STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-2242
Mailing Address - Country:US
Mailing Address - Phone:570-421-1960
Mailing Address - Fax:570-421-3548
Practice Address - Street 1:430 S. 7TH ST
Practice Address - Street 2:
Practice Address - City:LEHIGHTON
Practice Address - State:PA
Practice Address - Zip Code:18235-1824
Practice Address - Country:US
Practice Address - Phone:610-377-5177
Practice Address - Fax:610-377-5099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA131044261Q00000X
PA451044324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100773607Medicaid