Healthcare Provider Details

I. General information

NPI: 1023552908
Provider Name (Legal Business Name): MANDY DORIA, LPC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 N WASHINGTON AVE SUITE 601
SCRANTON PA
18503-1549
US

IV. Provider business mailing address

327 N WASHINGTON AVE SUITE 601
SCRANTON PA
18503-1549
US

V. Phone/Fax

Practice location:
  • Phone: 570-650-6450
  • Fax:
Mailing address:
  • Phone: 570-650-6450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPC007053
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: AMANDA DORIA ELLARD
Title or Position: OWNER, COUNSELOR
Credential: LPC
Phone: 570-650-6450