Provider Demographics
NPI:1770750481
Name:DIAKON LUTHERAN SOCIAL MINISTRIES
Entity type:Organization
Organization Name:DIAKON LUTHERAN SOCIAL MINISTRIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-795-0330
Mailing Address - Street 1:435 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-6001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:960 CENTURY DR
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055-4374
Practice Address - Country:US
Practice Address - Phone:717-795-0330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIAKON LUTHERAN SOCIAL MINISTRIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007777400061Medicaid