Healthcare Provider Details

I. General information

NPI: 1174755078
Provider Name (Legal Business Name): MARK WILLIAM DEITRICK LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 08/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 PORTERSVILLE RD
ELLWOOD CITY PA
16117-2431
US

IV. Provider business mailing address

2703 W STATE ST
NEW CASTLE PA
16101-8671
US

V. Phone/Fax

Practice location:
  • Phone: 724-752-9114
  • Fax: 724-657-3326
Mailing address:
  • Phone: 724-657-3303
  • Fax: 724-657-3326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC000115
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: