Healthcare Provider Details

I. General information

NPI: 1023407673
Provider Name (Legal Business Name): TAKING FLIGHT DEVELOPMENTAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2015
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1981 CATO AVE SUITE 2
STATE COLLEGE PA
16801-2754
US

IV. Provider business mailing address

301 S ALLEN ST STE 106
STATE COLLEGE PA
16801-4862
US

V. Phone/Fax

Practice location:
  • Phone: 814-954-4187
  • Fax: 814-954-4197
Mailing address:
  • Phone: 814-954-4187
  • Fax: 814-954-4197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC008556
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS-016201
License Number StatePA

VIII. Authorized Official

Name: ALISHA MUNDA
Title or Position: BUSINESS MANAGER
Credential:
Phone: 814-954-4187