Provider Demographics
NPI:1689025389
Name:CENTRE PROFESSIONAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:CENTRE PROFESSIONAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DERSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-689-9744
Mailing Address - Street 1:PO BOX 1120
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:PA
Mailing Address - Zip Code:16851-1120
Mailing Address - Country:US
Mailing Address - Phone:814-689-9744
Mailing Address - Fax:888-981-8069
Practice Address - Street 1:315 S ALLEN ST
Practice Address - Street 2:STE 216
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-4849
Practice Address - Country:US
Practice Address - Phone:814-689-9744
Practice Address - Fax:888-981-8069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-24
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056013L2084A0401X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty