Provider Demographics
NPI:1386776508
Name:BURNLEY WORKSHOP OF THE POCONOS
Entity type:Organization
Organization Name:BURNLEY WORKSHOP OF THE POCONOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:AMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-348-5371
Mailing Address - Street 1:4219 MANOR DR
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-9451
Mailing Address - Country:US
Mailing Address - Phone:570-992-6616
Mailing Address - Fax:570-992-5052
Practice Address - Street 1:4219 MANOR DR
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-9451
Practice Address - Country:US
Practice Address - Phone:570-992-6616
Practice Address - Fax:570-992-5052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA213490251C00000X
PACER-00093533251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA10000362007Medicaid