=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184787368
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY R CUSTER LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 W 10TH ST
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16502-1440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-455-4009
-----------------------------------------------------
Fax | 814-455-7715
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 138 EAST 26TH ST ATTN ANN MARIE ERNST
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-453-7138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | PC003084
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------