Provider Demographics
NPI:1699199091
Name:THE DEVEREUX FOUNDATION
Entity Type:Organization
Organization Name:THE DEVEREUX FOUNDATION
Other - Org Name:LISA LANE
Other - Org Type:Other Name
Authorized Official - Title/Position:REIMBURSEMENT ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-406-1637
Mailing Address - Street 1:PO BOX 490A
Mailing Address - Street 2:
Mailing Address - City:VILLANOVA
Mailing Address - State:PA
Mailing Address - Zip Code:19085-0290
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:487 LISA DR
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-1303
Practice Address - Country:US
Practice Address - Phone:610-431-8191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA121670320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100019130724Medicaid