Healthcare Provider Details

I. General information

NPI: 1669656492
Provider Name (Legal Business Name): NORTHEAST COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E BROAD ST
HAZLETON PA
18201-6835
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 Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number1007615710022
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier1007615710022
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: EDMUND ABDO JR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 570-735-7590