=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770597767
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNELLSVILLE COUNSELING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2006
-----------------------------------------------------
Last Update Date | 04/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 S ARCH ST
-----------------------------------------------------
City | CONNELLSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15425-3515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-626-9941
-----------------------------------------------------
Fax | 724-626-2785
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 S ARCH ST
-----------------------------------------------------
City | CONNELLSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15425-3515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-626-9941
-----------------------------------------------------
Fax | 724-626-2785
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MS. CAROLE GENE STERN
-----------------------------------------------------
Credential | PSYCHOLOGIST
-----------------------------------------------------
Telephone | 724-626-9941
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 323P00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number | 443260
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 443260
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 443260
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 443260
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number | 443260
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 103TM1800X
-----------------------------------------------------
Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
-----------------------------------------------------
License Number | 443260
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 443260
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 443260
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #11
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 443260
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------