01 FISCAL AGENT (WVR) TRANSITIONAL SUPPORT (WVR) 02 CHILDREN'S CHOICE (WVR)(IN-ST) 03 04 PEDI DAY HLTH CARE (IN-ST) MANAGED CARE ORG - PREPAID 05 06 NOW PROFESSIONAL SERVICES CASE MGMT-INFT & TODD (IN-ST) 07 OAAS CASE MGMT (IN-ST) 08 09 HOSPICE SERVICES (IN-ST) COMPREHENSIVE COMM SUPPORT SRV 10 11 SHARED LIVING (WVR) (IN-ST) MULTI-SYSTEMIC THER (IN-ST) 12 13 PREVOC REHAB (WVR) (IN-ST) 14 DAY HABILITAT (WVR) (IN-ST) ENVIR ACC ADAP (WVR) (IN-ST) 15 16 PERS EMERG RESP SYS (WVR) 17 ASSISTIVE DEVICES (WVR) 18 COMM MENTAL HLTH CTR/PART HOSP 19 DR OF OSTEOPATH MED (IND & GP) PHYSICIAN (IND & GP) 20 21 THIRD PARTY BILL AGT/SUBMITTER 22 PERSONAL CARE ATTENDANT (WVR) INDEPENDENT LAB 23 24 PERSONAL CARE SERVICES (IN-ST) MOBILE XRAY/RADIATION THRPY CT 25 26 PHARMACY DENTIST (IND & GP) 27 Provider Type Code Description 28 OPTOMETRIST (IND & GP) EARLYSTEPS (IND & GP) (IN-ST) 29 30 CHIROPRACTOR (IND & GP) 31 PSYCHOLOGIST (LIC/MED) (IN-ST) PODIATRIST (IND & GP) 32 33 PRESCRIBING ONLY PROVIDER AUDIOLOGIST (IN-ST) 34 35 PHYSICAL THERAPIST (IN-ST) 36 NOT ASSIGNED OCCUPATIONAL THERAPIST (IN-ST) 37 38 SCHOOL BSED HEALTH CTR (IN-ST) SPEECH/LANGUAGE THERAP (IN-ST) 39 40 DME 41 REGISTERED DIETICIAN (IN-ST) NON-EMER MED TRANSPORT (IN-ST) 42 43 CASE MGT - NHV/FTM (IN-ST) HOME HEALTH AGENCY (IN-ST) 44 45 CASE MGMT - CONTRACTOR (IN-ST) 46 CASE MGMT - HIV CASE MGMT - CMI 47 48 CASE MGMT - PREGNANT WOMEN CASE MGMT - DEVELOP DISABLED 49
01 FISCAL AGENT (WVR) 02 TRANSITIONAL SUPPORT (WVR) 03 CHILDREN'S CHOICE (WVR)(IN-ST) 04 PEDI DAY HLTH CARE (IN-ST) 05 MANAGED CARE ORG - PREPAID 06 NOW PROFESSIONAL SERVICES 07 CASE MGMT-INFT & TODD (IN-ST) 08 OAAS CASE MGMT (IN-ST) 09 HOSPICE SERVICES (IN-ST) 10 COMPREHENSIVE COMM SUPPORT SRV 11 SHARED LIVING (WVR) (IN-ST) 12 MULTI-SYSTEMIC THER (IN-ST) 13 PREVOC REHAB (WVR) (IN-ST) 14 DAY HABILITAT (WVR) (IN-ST) 15 ENVIR ACC ADAP (WVR) (IN-ST) 16 PERS EMERG RESP SYS (WVR) 17 ASSISTIVE DEVICES (WVR) 18 COMM MENTAL HLTH CTR/PART HOSP 19 DR OF OSTEOPATH MED (IND & GP) 20 PHYSICIAN (IND & GP) 21 THIRD PARTY BILL AGT/SUBMITTER 22 PERSONAL CARE ATTENDANT (WVR) 23 INDEPENDENT LAB 24 PERSONAL CARE SERVICES (IN-ST) 25 MOBILE XRAY/RADIATION THRPY CT 26 PHARMACY 27 DENTIST (IND & GP) Provider Type Code Description 28 OPTOMETRIST (IND & GP) 29 EARLYSTEPS (IND & GP) (IN-ST) 30 CHIROPRACTOR (IND & GP) 31 PSYCHOLOGIST (LIC/MED) (IN-ST) 32 PODIATRIST (IND & GP) 33 PRESCRIBING ONLY PROVIDER 34 AUDIOLOGIST (IN-ST) 35 PHYSICAL THERAPIST (IN-ST) 36 NOT ASSIGNED 37 OCCUPATIONAL THERAPIST (IN-ST) 38 SCHOOL BSED HEALTH CTR (IN-ST) 39 SPEECH/LANGUAGE THERAP (IN-ST) 40 DME 41 REGISTERED DIETICIAN (IN-ST) 42 NON-EMER MED TRANSPORT (IN-ST) 43 CASE MGT - NHV/FTM (IN-ST) 44 HOME HEALTH AGENCY (IN-ST) 45 CASE MGMT - CONTRACTOR (IN-ST) 46 CASE MGMT - HIV 47 CASE MGMT - CMI 48 CASE MGMT - PREGNANT WOMEN 49 CASE MGMT - DEVELOP DISABLED