Healthcare Provider Details

I. General information

NPI: 1366842692
Provider Name (Legal Business Name): OUT OF THE BOX THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 SPRUCE ST SUITE 511
SCRANTON PA
18503-1400
US

IV. Provider business mailing address

321 SPRUCE ST SUITE 511
SCRANTON PA
18503-1400
US

V. Phone/Fax

Practice location:
  • Phone: 570-209-7998
  • Fax: 570-955-0774
Mailing address:
  • Phone: 570-209-7998
  • Fax: 570-955-0774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC005186
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: ZIV BEN-DOV
Title or Position: OWNER/LPC
Credential: LPC
Phone: 570-209-7998