Healthcare Provider Details

I. General information

NPI: 1437527280
Provider Name (Legal Business Name): 4C LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2015
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 ZION RD
CLARION PA
16214-3254
US

IV. Provider business mailing address

425 RON MCHENRY RD
KNOX PA
16232-3009
US

V. Phone/Fax

Practice location:
  • Phone: 814-319-7217
  • Fax:
Mailing address:
  • Phone: 814-797-0256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberPC003785
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. SAMUEL GARY JOHNSON
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC
Phone: 814-319-7217