Healthcare Provider Details

I. General information

NPI: 1114372026
Provider Name (Legal Business Name): MAINSTREAMCOUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WASHINGTON ST
HUNTINGDON PA
16652-1826
US

IV. Provider business mailing address

900 WASHINGTON ST
HUNTINGDON PA
16652-1826
US

V. Phone/Fax

Practice location:
  • Phone: 814-643-1114
  • Fax: 814-643-5344
Mailing address:
  • Phone: 814-643-1114
  • Fax: 814-643-5344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number317013
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number317013
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number317013
License Number StatePA

VIII. Authorized Official

Name: LONNIE A WAGNERWOOMER
Title or Position: OWNER
Credential: LCSW
Phone: 814-643-1114