Provider Demographics
NPI:1255572426
Name:PASTUCKA, DAVID MICHAEL (MA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:PASTUCKA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S WYLAM ST
Mailing Address - Street 2:
Mailing Address - City:FRACKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17931-2424
Mailing Address - Country:US
Mailing Address - Phone:570-874-0333
Mailing Address - Fax:
Practice Address - Street 1:16 S CENTRE ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3001
Practice Address - Country:US
Practice Address - Phone:570-628-5234
Practice Address - Fax:570-682-9051
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005313L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1446230Medicaid