Provider Demographics
NPI:1568631513
Name:LUZERNE WYOMING COUNTY MENTAL HEALTH CENTER #1
Entity Type:Organization
Organization Name:LUZERNE WYOMING COUNTY MENTAL HEALTH CENTER #1
Other - Org Name:COMMUNITY COUNSELING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:H
Authorized Official - Last Name:KNECHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-552-3900
Mailing Address - Street 1:562 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3721
Mailing Address - Country:US
Mailing Address - Phone:570-552-3900
Mailing Address - Fax:570-552-3907
Practice Address - Street 1:562 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3721
Practice Address - Country:US
Practice Address - Phone:570-552-3900
Practice Address - Fax:570-552-3907
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUZERNE WYOMING COUNTY MENTAL HEALTH CENTER #1
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA222490261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000020800061Medicaid