Provider Demographics
NPI:1154424448
Name:DERSHEM, PATRICIA ANN (LCSW)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:DERSHEM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 WEST CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:AVIS
Mailing Address - State:PA
Mailing Address - Zip Code:17721-1070
Mailing Address - Country:US
Mailing Address - Phone:570-753-3620
Mailing Address - Fax:570-753-3620
Practice Address - Street 1:302 WEST CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:AVIS
Practice Address - State:PA
Practice Address - Zip Code:17721-1070
Practice Address - Country:US
Practice Address - Phone:570-753-3620
Practice Address - Fax:570-753-3620
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW008439L1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA062223S68OtherMEDICARE
PA2117726OtherCIGNA
PA474483OtherVALUE OPTIONS
PA1617662OtherBC/BS HIGHMARK
PA817938OtherFIRST PRIORITY HEALTH
PA1617662OtherBC/BS HIGHMARK
PA083604Medicare ID - Type UnspecifiedMEDICARE