Healthcare Provider Details

I. General information

NPI: 1649612805
Provider Name (Legal Business Name): EDWARD A PANE CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 W BROAD ST SUITE 308
HAZLETON PA
18201-6424
US

IV. Provider business mailing address

8 W BROAD ST STE 308
HAZLETON PA
18201-6427
US

V. Phone/Fax

Practice location:
  • Phone: 570-436-7022
  • Fax: 580-534-0997
Mailing address:
  • Phone: 570-436-7022
  • Fax: 570-534-0997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW129221
License Number StatePA

VII. Legacy identifiers

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

# 1
IdentifierSW129221
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerSOCIAL WORKER
# 2
Identifier0231
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCERTIFIED ADVANCED ALCOHOL AND DRUG COUNSELOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: