Healthcare Provider Details

I. General information

NPI: 1417103912
Provider Name (Legal Business Name): INNOVATIVE COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 03/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 BROADWAY
HANOVER PA
17331-2501
US

IV. Provider business mailing address

260 LYNBROOK DR N
YORK PA
17402-3228
US

V. Phone/Fax

Practice location:
  • Phone: 888-821-2935
  • Fax: 866-470-6121
Mailing address:
  • Phone: 888-821-2935
  • Fax: 866-470-6121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSOO6977
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberPS006977
License Number StatePA

VIII. Authorized Official

Name: DR. JEAN F POLLACK
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 888-821-2935