Provider Demographics
NPI:1689084741
Name:DIAKON CHILD, FAMILY & COMMUNITY
Entity Type:Organization
Organization Name:DIAKON CHILD, FAMILY & COMMUNITY
Other - Org Name:DIAKON FAMILY LIFE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-795-0368
Mailing Address - Street 1:435 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-6001
Mailing Address - Country:US
Mailing Address - Phone:570-322-7873
Mailing Address - Fax:570-322-8026
Practice Address - Street 1:571 MOUNTAIN RD # 10
Practice Address - Street 2:
Practice Address - City:BOILING SPRINGS
Practice Address - State:PA
Practice Address - Zip Code:17007-9520
Practice Address - Country:US
Practice Address - Phone:717-795-0330
Practice Address - Fax:717-795-0407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-29
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007777400060Medicaid