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General NPI Number Information
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NPI Number | 1174729990
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Entity Type | Organization
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Legal Business Name | DELUCA FAMILY WELLNESS CENTER, INC.
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Dates
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Enumeration Date | 06/27/2007
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Last Update Date | 01/01/2008
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Provider Practice Location Address
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Address Line | RT. 2 BOX 406 SUITE 121
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City | CLARKSBURG
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State | WV
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Zip | 26301
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Country | US
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Telephone | 304-626-3541
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Fax | 304-626-3174
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Provider Business Mailing Address
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Address Line | RT. 2 BOX 406 SUITE 121
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City | CLARKSBURG
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State | WV
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Zip | 26301
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Country | US
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Telephone | 304-626-3541
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Fax | 304-626-3174
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. MATTHEW JOSEPH DELUCA
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Credential | M.S. , LPC
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Telephone | 304-626-3541
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 1540
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License Number State | WV
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