Healthcare Provider Details

I. General information

NPI: 1104156157
Provider Name (Legal Business Name): BRENDA DAUGHERTY-SHRIVASTAVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2010
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PINNACLE DR
CLARION PA
16214-3800
US

IV. Provider business mailing address

100 SHENANGO AVE
SHARON PA
16146-1503
US

V. Phone/Fax

Practice location:
  • Phone: 814-223-9914
  • Fax: 814-223-9917
Mailing address:
  • Phone: 814-223-9914
  • Fax: 814-223-9917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC000561
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC000561
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierPC000561
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerLICENSED PROFESSIONAL COUNSELOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: