Provider Demographics
NPI:1578983219
Name:COUPLES AT CROSSROADS
Entity Type:Organization
Organization Name:COUPLES AT CROSSROADS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:D
Authorized Official - Last Name:THIESSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:717-433-5751
Mailing Address - Street 1:5006 LENKER ST
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-3202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5006 LENKER ST
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-3202
Practice Address - Country:US
Practice Address - Phone:717-433-5751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMF000107106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty