Provider Demographics
NPI:1831536853
Name:PROJECT STARPHISH
Entity type:Organization
Organization Name:PROJECT STARPHISH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR OF PROGRAM SUPPORT
Authorized Official - Prefix:MS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:814-661-2780
Mailing Address - Street 1:PO BOX 771
Mailing Address - Street 2:
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214-0771
Mailing Address - Country:US
Mailing Address - Phone:814-661-2780
Mailing Address - Fax:
Practice Address - Street 1:10987 ROUTE 322
Practice Address - Street 2:
Practice Address - City:SHIPPENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16254-4837
Practice Address - Country:US
Practice Address - Phone:814-661-2780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REIGNBOW ENTERPRISES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA444590251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health