Healthcare Provider Details

I. General information

NPI: 1548778202
Provider Name (Legal Business Name): WATERSHED COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 11/04/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 W. MAIN ST. SUITE 110
NORTH EAST PA
16428-1333
US

IV. Provider business mailing address

143 WEST MAIN STREET SUITE 110
NORTH EAST PA
16428-1333
US

V. Phone/Fax

Practice location:
  • Phone: 814-347-5018
  • Fax: 814-347-5186
Mailing address:
  • Phone: 814-347-5018
  • Fax: 814-347-5186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberPC010131
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberPC010131
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberPC010131
License Number StatePA

VIII. Authorized Official

Name: ANGELA FRANK
Title or Position: OWNER/DIRECTOR
Credential: LPC, NCC, CAADC
Phone: 814-347-5018