Provider Demographics
NPI:1275844789
Name:CONNELLSVILLE COUNSELING & PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:CONNELLSVILLE COUNSELING & PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROXANE
Authorized Official - Middle Name:
Authorized Official - Last Name:MONGELLUZZO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:724-626-8420
Mailing Address - Street 1:416 S PITTSBURGH ST
Mailing Address - Street 2:
Mailing Address - City:CONNELLSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15425-4003
Mailing Address - Country:US
Mailing Address - Phone:724-626-8420
Mailing Address - Fax:724-628-0898
Practice Address - Street 1:416 S PITTSBURGH ST
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-4003
Practice Address - Country:US
Practice Address - Phone:724-626-8420
Practice Address - Fax:724-628-0898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATO BE ASSIGNED251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PATO BE ASSIGNEDMedicaid