Provider Demographics
NPI:1780018424
Name:PROSTAT, INC.
Entity Type:Organization
Organization Name:PROSTAT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SHELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:610-736-9000
Mailing Address - Street 1:1901 BERNVILLE RD
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19601-1113
Mailing Address - Country:US
Mailing Address - Phone:610-736-9000
Mailing Address - Fax:
Practice Address - Street 1:1901 BERNVILLE RD
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19601-1113
Practice Address - Country:US
Practice Address - Phone:610-736-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-29
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA343800000XMedicaid
PA1024232050001Medicaid
PA1024232050002Medicaid
PA1024232050003Medicaid