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General NPI Number Information
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NPI Number | 1679100523
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Entity Type | Organization
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Legal Business Name | MYCOCUN, INC.
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Dates
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Enumeration Date | 03/23/2020
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Last Update Date | 03/23/2020
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Provider Practice Location Address
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Address Line | 115 RED OAK DR
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City | LINCOLN UNIVERSITY
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State | PA
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Zip | 19352-8939
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Country | US
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Telephone | 267-908-4664
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Fax |
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Provider Business Mailing Address
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Address Line | 115 RED OAK DR
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City | LINCOLN UNIVERSITY
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State | PA
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Zip | 19352-8939
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Country | US
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Telephone | 672-908-4664
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR & DEVELOPMENT
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Name | JENNIFER MORGAN RAKAY
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Credential | MA, LPC, BC-DMT
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Telephone | 267-908-4664
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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