Healthcare Provider Details

I. General information

NPI: 1154602506
Provider Name (Legal Business Name): JEAN MARIE GRUBER BARZILOSKI MS, LPC, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 MAIN ST
HONESDALE PA
18431-1847
US

IV. Provider business mailing address

840 MAIN ST
HONESDALE PA
18431-1847
US

V. Phone/Fax

Practice location:
  • Phone: 570-470-4826
  • Fax:
Mailing address:
  • Phone: 470-470-4826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC008357
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN004646
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: