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General NPI Number Information
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NPI Number | 1245737147
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Entity Type | Organization
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Legal Business Name | INDIAN CREEK VALLEY CHRISTIAN FAMILY & CHILDREN'S CENTER
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Dates
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Enumeration Date | 04/09/2018
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 2166 INDIAN HEAD RD
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City | CHAMPION
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State | PA
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Zip | 15622-3019
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Country | US
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Telephone | 724-455-2122
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Fax | 724-455-6651
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Provider Business Mailing Address
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Address Line | 2166 INDIAN HEAD RD
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City | CHAMPION
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State | PA
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Zip | 15622-3019
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Country | US
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Telephone | 724-455-2122
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Fax | 724-455-6651
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. DWIGHT MERLE SKINNER II
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Credential | LPC
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Telephone | 724-455-2122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | PC010268
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License Number State | PA
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