Healthcare Provider Details

I. General information

NPI: 1063713519
Provider Name (Legal Business Name): KALEIDOSCOPE OF LIFE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 11/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 S TULPEHOCKEN ST
PINE GROVE PA
17963-1067
US

IV. Provider business mailing address

183 S TULPEHOCKEN ST
PINE GROVE PA
17963-1067
US

V. Phone/Fax

Practice location:
  • Phone: 570-789-3599
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberPC005421
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberPC005421
License Number StatePA

VIII. Authorized Official

Name: MRS. JANELLA LYNN PODA-HENRY
Title or Position: OWER/PSYCHOTHERAPIST
Credential: LPC
Phone: 570-789-3599