Provider Demographics
NPI:1992376651
Name:STELLAR SUPPORT SERVICE
Entity Type:Organization
Organization Name:STELLAR SUPPORT SERVICE
Other - Org Name:STELLAR SUPPORT SERVICE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:D'AVANZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-996-6263
Mailing Address - Street 1:620 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MCKEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:15132-3503
Mailing Address - Country:US
Mailing Address - Phone:412-996-6263
Mailing Address - Fax:
Practice Address - Street 1:15009 NORTH PRESTON HIGHWAY
Practice Address - Street 2:SUITE A
Practice Address - City:BRUCETON MILLS
Practice Address - State:WV
Practice Address - Zip Code:26525
Practice Address - Country:US
Practice Address - Phone:681-270-9223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-05
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103235783Medicaid