Provider Demographics
NPI:1750581609
Name:WHITE DEER RUN, INC
Entity type:Organization
Organization Name:WHITE DEER RUN, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:PROCOPIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-255-2335
Mailing Address - Street 1:202 COVE FORGE ROAD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16693-9673
Mailing Address - Country:US
Mailing Address - Phone:800-873-2131
Mailing Address - Fax:
Practice Address - Street 1:202 COVE FORGE ROAD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:PA
Practice Address - Zip Code:16693-9673
Practice Address - Country:US
Practice Address - Phone:800-873-2131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA077009101YA0400X, 103TA0400X, 261Q00000X, 261QR0405X, 322D00000X, 323P00000X, 324500000X, 3245S0500X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, ChildrenGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007567870023Medicaid