Provider Demographics
NPI:1306984448
Name:COUNTY OF WAYNE
Entity type:Organization
Organization Name:COUNTY OF WAYNE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MHMR ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:ENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-253-9200
Mailing Address - Street 1:648 PARK ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-1446
Mailing Address - Country:US
Mailing Address - Phone:570-253-9200
Mailing Address - Fax:
Practice Address - Street 1:648 PARK ST
Practice Address - Street 2:SUITE A
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-1446
Practice Address - Country:US
Practice Address - Phone:570-253-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAYNE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-01
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA225140251K00000X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017310820014Medicaid
PA10017310820003Medicaid