=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245477975
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORNERSTONE COUNSELING & CONSULTING SPECIALISTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2009
-----------------------------------------------------
Last Update Date | 10/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1172 TWIN STACKS DR
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18612-8505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-674-1505
-----------------------------------------------------
Fax | 570-674-8679
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1172 TWIN STACKS DRIVE
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18612-9178
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-674-1505
-----------------------------------------------------
Fax | 570-674-8679
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | MS. MARIE COLETTE GRAY
-----------------------------------------------------
Credential | PHD; NCP; LPC; FAAGB
-----------------------------------------------------
Telephone | 570-674-1505
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | PC-003840
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS005483L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | PC003840
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------