Provider Demographics
NPI:1629104682
Name:LUZERNE WYOMING COUNTIES MENTAL HEALTH MENTAL RETARDATION PROGRAM
Entity Type:Organization
Organization Name:LUZERNE WYOMING COUNTIES MENTAL HEALTH MENTAL RETARDATION PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MH MR ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CISOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-825-9441
Mailing Address - Street 1:200 N RIVER ST
Mailing Address - Street 2:TREASURER LUZERNE COUNTY
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18711-1004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 N PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-3511
Practice Address - Country:US
Practice Address - Phone:570-831-7277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management