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General NPI Number Information
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NPI Number | 1174755078
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Entity Type | Individual
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Provider Name | MARK WILLIAM DEITRICK LPC
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Gender | Male
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Dates
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Enumeration Date | 08/11/2009
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Last Update Date | 08/09/2010
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Provider Practice Location Address
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Address Line | 229 PORTERSVILLE RD
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City | ELLWOOD CITY
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State | PA
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Zip | 16117-2431
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Country | US
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Telephone | 724-752-9114
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Fax | 724-657-3326
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Provider Business Mailing Address
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Address Line | 2703 W STATE ST
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City | NEW CASTLE
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State | PA
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Zip | 16101-8671
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Country | US
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Telephone | 724-657-3303
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Fax | 724-657-3326
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | PC000115
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License Number State | PA
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