Healthcare Provider Details

I. General information

NPI: 1952903601
Provider Name (Legal Business Name): NORTHEAST COUNSELING SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/09/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W 23RD ST
HAZLE TOWNSHIP PA
18202-1541
US

IV. Provider business mailing address

750 E BROAD ST
HAZLETON PA
18201-6835
US

V. Phone/Fax

Practice location:
  • Phone: 570-455-6385
  • Fax:
Mailing address:
  • Phone: 570-455-6385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier229800
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: RICH ZABINSKI
Title or Position: MIS DIRECTOR
Credential:
Phone: 570-455-6385