Provider Demographics
NPI:1306960091
Name:DEVEREUX KANNER
Entity type:Organization
Organization Name:DEVEREUX KANNER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NATIONAL DIRECTOR, AR
Authorized Official - Prefix:
Authorized Official - First Name:FRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-542-3084
Mailing Address - Street 1:2012 RENAISSANCE BLVD
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-2786
Mailing Address - Country:US
Mailing Address - Phone:610-542-3084
Mailing Address - Fax:610-542-3191
Practice Address - Street 1:390 E BOOT RD
Practice Address - Street 2:101 GENUARDI CIRCLE
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-1222
Practice Address - Country:US
Practice Address - Phone:610-431-8100
Practice Address - Fax:610-431-3155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA112050320800000X
PA132880322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0010537Medicaid