MEDICARE: CORNERSTONE COUNSELING & CONSULTING SPECIALISTS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	PC-003840	PA
2	101YP2500X	Professional Counselor
3	103TC0700X	Clinical Psychologist	PS005483L	PA
4	103TC2200X	Clinical Child & Adolescent Psychologist		PA
5	101YP2500X	Professional Counselor	PC003840	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1023152530001	OTHER	PA	DPW
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245477975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNERSTONE COUNSELING & CONSULTING SPECIALISTS LLC

Provider Business Mailing Address
First Line	:	1172 TWIN STACKS DRIVE
Second Line	:
City	:	DALLAS
State	:	PA
Zip	:	18612-9178
Country	:	US
Telephone Number	:	570-674-1505
Fax Number	:	570-674-8679

Provider Business Practice Location Address
First Line	:	1172 TWIN STACKS DR
Second Line	:
City	:	DALLAS
State	:	PA
Zip	:	18612-8505
Country	:	US
Telephone Number	:	570-674-1505
Fax Number	:	570-674-8679

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	MS. MARIE COLETTE GRAY
Credential	:	PHD; NCP; LPC; FAAGB
Telephone Number	:	570-674-1505

Provider Enumeration Date	:	01/16/2009
Last Update Date	:	10/05/2015

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