Healthcare Provider Details

I. General information

NPI: 1245737147
Provider Name (Legal Business Name): INDIAN CREEK VALLEY CHRISTIAN FAMILY & CHILDREN'S CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2166 INDIAN HEAD RD
CHAMPION PA
15622-3019
US

IV. Provider business mailing address

2166 INDIAN HEAD RD
CHAMPION PA
15622-3019
US

V. Phone/Fax

Practice location:
  • Phone: 724-455-2122
  • Fax: 724-455-6651
Mailing address:
  • Phone: 724-455-2122
  • Fax: 724-455-6651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC010268
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. DWIGHT MERLE SKINNER II
Title or Position: EXECUTIVE DIRECTOR
Credential: LPC
Phone: 724-455-2122