Provider Demographics
| NPI: | 1134158314 |
|---|---|
| Name: | DEERFIELD BEHAVIORAL HEALTH OF WARREN, LLC |
| Entity type: | Organization |
| Organization Name: | DEERFIELD BEHAVIORAL HEALTH OF WARREN, LLC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | MEDICAL DIRECTOR |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | JOHN |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | JOHN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 814-723-5545 |
| Mailing Address - Street 1: | 1003 PENNSYLVANIA AVE W FL 2 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | WARREN |
| Mailing Address - State: | PA |
| Mailing Address - Zip Code: | 16365-1876 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 814-723-5545 |
| Mailing Address - Fax: | 814-723-6355 |
| Practice Address - Street 1: | 1003 PENNSYLVANIA AVE W |
| Practice Address - Street 2: | |
| Practice Address - City: | WARREN |
| Practice Address - State: | PA |
| Practice Address - Zip Code: | 16365-1876 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 814-723-5545 |
| Practice Address - Fax: | 814-723-6355 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-07-01 |
| Last Update Date: | 2024-07-29 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| PA | PC004260 | 101YP2500X |
| PA | PC001117 | 101YP2500X |
| PA | PS006787L | 103TC0700X |
| PA | SW123097 | 104100000X |
| PA | CW013526 | 1041C0700X |
| PA | MD055978L | 2084P0800X, 2084P0802X |
| PA | MD016835E | 2084P0800X |
| PA | MD051025L | 2084P0800X |
| PA | MD042901L | 2084P0800X |
| PA | MD061131L | 2084P0800X |
| PA | MD425828 | 2084P0804X |
| PA | 627023 | 261QR0405X |
| PA | UP006505B | 363L00000X |
| PA | MD050021L | 2084P0800X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 2084P0802X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | Group - Multi-Specialty |
| No | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | Group - Multi-Specialty |
| No | 261QR0405X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | Group - Multi-Specialty |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| PA | 0015930840007 | Medicaid | |
| PA | 0050598001 | Other | UNIVERA HEALTH CARE |
| 330194 | Other | VALUE OPTIONS | |
| PA | 0015930840010 | Medicaid | |
| PA | CD5207 | Other | RAILROAD MEDICARE |
| PA | 0015930840009 | Medicaid | |
| PA | 0015930840012 | Medicaid | |
| PA | 0828 | Other | HIGHMARK FACILITY |
| PA | 1436227 | Other | KEYSTONE HIGHMARK |
| PA | 0015930840011 | Medicaid | |
| PA | 1436176 | Other | HIGHMARK BLUE SHIELD |
| PA | 0015930840009 | Medicaid | |
| 330194 | Other | VALUE OPTIONS |
