Provider Demographics
NPI:1942503560
Name:DEMENTIA CONNECTION LLC
Entity Type:Organization
Organization Name:DEMENTIA CONNECTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO AND FOUNDER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:SCANLAND
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP GNP BC
Authorized Official - Phone:570-586-0655
Mailing Address - Street 1:104 APPLE VALLEY CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH ABINGTON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18411-9498
Mailing Address - Country:US
Mailing Address - Phone:570-586-0655
Mailing Address - Fax:570-586-5174
Practice Address - Street 1:2500 ADAMS AVE
Practice Address - Street 2:HOLY FAMILY RESIDENCE
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18509-1515
Practice Address - Country:US
Practice Address - Phone:570-343-4065
Practice Address - Fax:570-343-0448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-21
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP000593C363LA2200X
PASP010872363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1583600PABSOtherPA BLUE SHIELD
PA1583600PABSOtherPA BLUE SHIELD
PAMC022849Medicare PIN