Provider Demographics
NPI:1063717064
Name:CONEWAGO INDIANA
Entity type:Organization
Organization Name:CONEWAGO INDIANA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROJECT DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DESANTO
Authorized Official - Suffix:
Authorized Official - Credentials:LSW, CCDP-D
Authorized Official - Phone:570-601-0877
Mailing Address - Street 1:9143 ROUTE 119 HIGHWAY SOUTH
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15717-6731
Mailing Address - Country:US
Mailing Address - Phone:724-471-3037
Mailing Address - Fax:724-471-7105
Practice Address - Street 1:9143 ROUTE 119 HIGHWAY SOUTH
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15717-6731
Practice Address - Country:US
Practice Address - Phone:724-471-3037
Practice Address - Fax:724-471-7105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA327023251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health