Provider Demographics
NPI:1417386160
Name:PEERSTAR ADVOCACY ALLIANCE LLC
Entity Type:Organization
Organization Name:PEERSTAR ADVOCACY ALLIANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:NULTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:814-262-0025
Mailing Address - Street 1:210 COLLEGE PARK PLZ
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-2833
Mailing Address - Country:US
Mailing Address - Phone:814-266-1491
Mailing Address - Fax:814-266-1548
Practice Address - Street 1:399 GREEN AVE EXT
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-3404
Practice Address - Country:US
Practice Address - Phone:814-266-1491
Practice Address - Fax:814-266-1548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-04
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028643170001Medicaid
PA1028643170002Medicaid