Provider Demographics
NPI:1891816948
Name:NORTHERN TIER COUNSELING, INC
Entity Type:Organization
Organization Name:NORTHERN TIER COUNSELING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:DENAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-265-0100
Mailing Address - Street 1:RR 1 BOX 137
Mailing Address - Street 2:
Mailing Address - City:TOWANDA
Mailing Address - State:PA
Mailing Address - Zip Code:18848-9730
Mailing Address - Country:US
Mailing Address - Phone:570-265-0100
Mailing Address - Fax:570-265-6741
Practice Address - Street 1:MAIN STREET
Practice Address - Street 2:
Practice Address - City:LAPORTE
Practice Address - State:PA
Practice Address - Zip Code:18626
Practice Address - Country:US
Practice Address - Phone:570-265-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2084P0800X, 261QM0801X
PA201550261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA753722Medicare ID - Type UnspecifiedMEDICARE PROVIDER #