Provider Demographics
NPI:1538389614
Name:CENTRE COUNTY MH MR DA
Entity type:Organization
Organization Name:CENTRE COUNTY MH MR DA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-355-6782
Mailing Address - Street 1:420 HOLMES ST
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:BELLEFONTE
Mailing Address - State:PA
Mailing Address - Zip Code:16823-1401
Mailing Address - Country:US
Mailing Address - Phone:814-355-6782
Mailing Address - Fax:814-355-6985
Practice Address - Street 1:420 HOLMES ST
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:BELLEFONTE
Practice Address - State:PA
Practice Address - Zip Code:16823-1401
Practice Address - Country:US
Practice Address - Phone:814-355-6782
Practice Address - Fax:814-355-6985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007296630010Medicaid