Healthcare Provider Details

I. General information

NPI: 1740447648
Provider Name (Legal Business Name): NORTHEAST COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 05/19/2008
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 Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number1007615710021
License Number StatePA

VIII. Authorized Official

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