Provider Demographics
NPI:1336210699
Name:VIAQUEST BEHAVIAORL HEALTH OF PA, LLC
Entity Type:Organization
Organization Name:VIAQUEST BEHAVIAORL HEALTH OF PA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-645-3267
Mailing Address - Street 1:525 METRO PL N
Mailing Address - Street 2:SUITE 450
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-5342
Mailing Address - Country:US
Mailing Address - Phone:800-645-3267
Mailing Address - Fax:
Practice Address - Street 1:25 WOODS LN
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-2082
Practice Address - Country:US
Practice Address - Phone:717-242-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA316910261QM0855X
PA301480320800000X
PA302410320800000X
PA316970322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Not Answered320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019621050003Medicaid
PA0019621050001Medicaid
PA0019621050004Medicaid
PA0019621050002Medicaid
PA0428OtherBLUE CROSS PROVIDER #
PA5011962105OtherCBHNP PROVIDER #