Provider Demographics
NPI:1770636573
Name:LYCOMING-CLINTON MHMR PROGRAM
Entity Type:Organization
Organization Name:LYCOMING-CLINTON MHMR PROGRAM
Other - Org Name:LYCOMING-CLINTON JOINDER BOARD
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DOBORAH
Authorized Official - Middle Name:M
Authorized Official - Last Name:DUFFY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-326-7895
Mailing Address - Street 1:200 EAST STREET
Mailing Address - Street 2:THE SHARWELL BUILDING
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701
Mailing Address - Country:US
Mailing Address - Phone:570-326-0924
Mailing Address - Fax:570-326-1348
Practice Address - Street 1:200 EAST STREET
Practice Address - Street 2:THE SHARWELL BUILDING
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701
Practice Address - Country:US
Practice Address - Phone:570-326-0924
Practice Address - Fax:570-326-1348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004649L103T00000X
171M00000X, 251B00000X, 251J00000X, 251K00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251J00000XAgenciesNursing CareGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or WelfareGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty