Provider Demographics
NPI:1902026271
Name:CHILDREN'S SERVICE CENTER OF WYOMING VALLEY
Entity Type:Organization
Organization Name:CHILDREN'S SERVICE CENTER OF WYOMING VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-825-6425
Mailing Address - Street 1:335 S FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-3808
Mailing Address - Country:US
Mailing Address - Phone:570-825-6425
Mailing Address - Fax:
Practice Address - Street 1:335 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-3808
Practice Address - Country:US
Practice Address - Phone:570-825-6425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
PA1007280110008261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251S00000XAgenciesCommunity/Behavioral Health
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007280008Medicaid