Provider Demographics
NPI:1053791566
Name:TREHAB DRUG AND ALCOHOL OUTPATIENT PROGRAM
Entity type:Organization
Organization Name:TREHAB DRUG AND ALCOHOL OUTPATIENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-278-3338
Mailing Address - Street 1:36 PUBLIC AVENUE
Mailing Address - Street 2:PO BOX 366
Mailing Address - City:MONTROSE
Mailing Address - State:PA
Mailing Address - Zip Code:18801-1603
Mailing Address - Country:US
Mailing Address - Phone:570-278-3338
Mailing Address - Fax:
Practice Address - Street 1:1224 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUSQUEHANNA
Practice Address - State:PA
Practice Address - Zip Code:18847-2608
Practice Address - Country:US
Practice Address - Phone:570-853-2303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TREHAB
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-01
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA4JB06601251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health