Basic Information
| Provider Information | |||||||||
| NPI: | 1740516293 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDOP BEHAVIORAL HEALTH ASSOCIATES OF PENNSYLVANIA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 HATCHETTS HILL RD | ||||||||
| Address2: | |||||||||
| City: | OLD LYME | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063711534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003703651 | ||||||||
| FaxNumber: | 8605100020 | ||||||||
| Practice Location | |||||||||
| Address1: | 2595 INTERSTATE DRIVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171109380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108322279 | ||||||||
| FaxNumber: | 8605100020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2009 | ||||||||
| LastUpdateDate: | 08/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | DOOLEY | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8003703651 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDOPT SERVICES LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 1041C0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0805X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LP0808X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 364SP0809X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult | 103TC0700X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.