Provider Demographics
NPI:1104970227
Name:LYCOMING COUNTY CRIPPLED CHILDREN'S
Entity type:Organization
Organization Name:LYCOMING COUNTY CRIPPLED CHILDREN'S
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:P
Authorized Official - Last Name:PERROTTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-326-0565
Mailing Address - Street 1:625 W EDWIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701
Mailing Address - Country:US
Mailing Address - Phone:570-326-0565
Mailing Address - Fax:570-329-2522
Practice Address - Street 1:625 W EDWIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701
Practice Address - Country:US
Practice Address - Phone:570-326-0565
Practice Address - Fax:570-329-2522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT000490E225100000X
PAPT002737L225100000X
PAPT016332L225100000X
PAOC006418L225X00000X
PASL002712L235Z00000X
PAPS005489L103G00000X, 103T00000X, 103TC0700X
PASL000825L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100004601Medicaid
PA43093OtherGEISINGER HEALTH PLAN
PA000999239OtherHIGHMARK BLUE SHIELD
PA1000046010005Medicaid