Provider Demographics
NPI:1790006765
Name:FIRETREE, LTD.
Entity Type:Organization
Organization Name:FIRETREE, LTD.
Other - Org Name:CONEWAGO SNYDER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DESANTO
Authorized Official - Suffix:
Authorized Official - Credentials:LSW, CCDP-D
Authorized Official - Phone:570-322-0520
Mailing Address - Street 1:800 W 4TH ST
Mailing Address - Street 2:SUITE G-01
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-5895
Mailing Address - Country:US
Mailing Address - Phone:570-322-0520
Mailing Address - Fax:570-326-9674
Practice Address - Street 1:18336 ROUTE 522
Practice Address - Street 2:
Practice Address - City:BEAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:17813-9004
Practice Address - Country:US
Practice Address - Phone:570-658-7383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA557054251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health