Provider Demographics
NPI:1245477975
Name:CORNERSTONE COUNSELING & CONSULTING SPECIALISTS LLC
Entity type:Organization
Organization Name:CORNERSTONE COUNSELING & CONSULTING SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:COLETTE
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD; NCP; LPC; FAAGB
Authorized Official - Phone:570-674-1505
Mailing Address - Street 1:1172 TWIN STACKS DRIVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-9178
Mailing Address - Country:US
Mailing Address - Phone:570-674-1505
Mailing Address - Fax:570-674-8679
Practice Address - Street 1:1172 TWIN STACKS DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:PA
Practice Address - Zip Code:18612-8505
Practice Address - Country:US
Practice Address - Phone:570-674-1505
Practice Address - Fax:570-674-8679
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORNERSTONE COUNSELING & CONSULTING SPECIALISTS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-16
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC-003840101YP2500X
101YP2500X
PAPS005483L103TC0700X
PA103TC2200X
PAPC003840101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023152530001OtherDPW
PA1023152530002Medicaid
PA1033152530002Medicaid