Provider Demographics
NPI:1073387486
Name:BEHAVIORAL WELLNESS GROUP
Entity Type:Organization
Organization Name:BEHAVIORAL WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PRALL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MS, CRC, LPC
Authorized Official - Phone:570-780-6558
Mailing Address - Street 1:1819 MAIN ST # A
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:PA
Mailing Address - Zip Code:18447-1351
Mailing Address - Country:US
Mailing Address - Phone:570-780-6558
Mailing Address - Fax:
Practice Address - Street 1:1819 MAIN ST # A
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:PA
Practice Address - Zip Code:18447-1351
Practice Address - Country:US
Practice Address - Phone:570-780-6558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty