Provider Demographics
NPI:1740305218
Name:ITSA PLAYFUL JOURNEY
Entity type:Organization
Organization Name:ITSA PLAYFUL JOURNEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHILD AND FAMILY THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:MATHIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MHS, LPC, RPT-S
Authorized Official - Phone:717-431-2027
Mailing Address - Street 1:2173 EMBASSY DR.,
Mailing Address - Street 2:SUITE 164
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603
Mailing Address - Country:US
Mailing Address - Phone:717-431-2027
Mailing Address - Fax:717-431-2014
Practice Address - Street 1:2173 EMBASSY DR.,
Practice Address - Street 2:SUITE 164
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603
Practice Address - Country:US
Practice Address - Phone:717-431-2027
Practice Address - Fax:717-431-2014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC003842101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPC003842OtherLICENSED PROFESSIONAL
PAMIS220198000OtherMAGELLAN HEALTH SERVICES
PA50064527OtherCAPITAL BLUE CROSS