Provider Demographics
NPI:1215568431
Name:NORTHEASTERN BEHAVIORAL HEALTH, PC
Entity Type:Organization
Organization Name:NORTHEASTERN BEHAVIORAL HEALTH, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOWALIK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CAADC
Authorized Official - Phone:570-832-4339
Mailing Address - Street 1:140 BENNETT AVENUE
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18338
Mailing Address - Country:US
Mailing Address - Phone:570-832-4339
Mailing Address - Fax:
Practice Address - Street 1:140 BENNETT AVENUE
Practice Address - Street 2:SUITE 1B
Practice Address - City:MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18337
Practice Address - Country:US
Practice Address - Phone:570-832-4339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder