Healthcare Provider Details

I. General information

NPI: 1891575353
Provider Name (Legal Business Name): KRYSTAL LYNN KOTACSKA LGPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 HOMESTEAD DR
HANOVER PA
17331-8052
US

IV. Provider business mailing address

196 HOMESTEAD DR
HANOVER PA
17331-8052
US

V. Phone/Fax

Practice location:
  • Phone: 717-324-7581
  • Fax:
Mailing address:
  • Phone: 717-324-7581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP14273
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: