Healthcare Provider Details

I. General information

NPI: 1659030328
Provider Name (Legal Business Name): MARK ALAN STOLTZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

993 BEAVER DR
DU BOIS PA
15801-2513
US

IV. Provider business mailing address

1194 TREASURE LK
DU BOIS PA
15801-9028
US

V. Phone/Fax

Practice location:
  • Phone: 814-771-5544
  • Fax:
Mailing address:
  • Phone: 814-771-5544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK A STOLTZ
Title or Position: OWNER
Credential: LCSW
Phone: 814-771-5544