Provider Demographics
NPI:1821469867
Name:DIAKON CHILD FAMILY AND COMMUNITY MINISTRIES
Entity Type:Organization
Organization Name:DIAKON CHILD FAMILY AND COMMUNITY MINISTRIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-322-7873
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:
Mailing Address - Fax:
Practice Address - Street 1:2800 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-4139
Practice Address - Country:US
Practice Address - Phone:570-322-7873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIAKON LUTHERAN SOCIAL MINISTRIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA331600251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA379904OtherMEDICARE PTAN
PA1029202560001Medicaid