Healthcare Provider Details

I. General information

NPI: 1053253294
Provider Name (Legal Business Name): MICHAEL KASOMENAKIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2026
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 S ALLEN ST STE 303
STATE COLLEGE PA
16801-5946
US

IV. Provider business mailing address

1315 S ALLEN ST STE 303
STATE COLLEGE PA
16801-5946
US

V. Phone/Fax

Practice location:
  • Phone: 814-419-5463
  • Fax:
Mailing address:
  • Phone: 814-419-5463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPC002311
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: