Provider Demographics
NPI:1598336133
Name:RADIANCE WELLNESS GROUP LLC
Entity Type:Organization
Organization Name:RADIANCE WELLNESS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PLOCINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:570-601-4325
Mailing Address - Street 1:1341 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-5409
Mailing Address - Country:US
Mailing Address - Phone:570-601-4325
Mailing Address - Fax:570-866-3141
Practice Address - Street 1:953 MARKET ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3448
Practice Address - Country:US
Practice Address - Phone:570-601-4325
Practice Address - Fax:570-866-3141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-06
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1034210900007Medicaid
PA1038257700001Medicaid
PA1037997140001Medicaid
PA1039567180002Medicaid
PA1034210900002Medicaid
PA1038257700002Medicaid
PA1039455450002Medicaid