Provider Demographics
NPI:1801271010
Name:PSYCH CONSULTANTS IN LUZERNE VALLEY
Entity type:Organization
Organization Name:PSYCH CONSULTANTS IN LUZERNE VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CICCHIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:570-875-8058
Mailing Address - Street 1:601 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:PA
Mailing Address - Zip Code:17851-1803
Mailing Address - Country:US
Mailing Address - Phone:570-875-8058
Mailing Address - Fax:570-554-4357
Practice Address - Street 1:601 W 5TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:PA
Practice Address - Zip Code:17851-1803
Practice Address - Country:US
Practice Address - Phone:570-875-8058
Practice Address - Fax:570-554-4357
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PSYCH CONSULTANTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP006931C363LA2200X, 364SP0807X
PASP009838364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & AdolescentGroup - Single Specialty