Healthcare Provider Details

I. General information

NPI: 1679156160
Provider Name (Legal Business Name): LEAH LYNN PETERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 E 8TH ST
WEST WYOMING PA
18644-2010
US

IV. Provider business mailing address

417 HOLDEN ST
WEST WYOMING PA
18644-1511
US

V. Phone/Fax

Practice location:
  • Phone: 570-655-1667
  • Fax:
Mailing address:
  • Phone: 570-814-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC006094
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: