Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 103TA0400X | Psychologist | Addiction (Substance Use Disorder) | 077009 | PENNSYLVANIA | No |
| 2 | 261Q00000X | Clinic/Center | | 077009 | PENNSYLVANIA | No |
| 3 | 261QR0405X | Clinic/Center | Rehabilitation, Substance Use Disorder | 077009 | PENNSYLVANIA | No |
| 4 | 322D00000X | Residential Treatment Facility, Emotionally Disturbed Children | | 077009 | PENNSYLVANIA | No |
| 5 | 323P00000X | Psychiatric Residential Treatment Facility | | 077009 | PENNSYLVANIA | No |
| 6 | 324500000X | Substance Abuse Rehabilitation Facility | | 077009 | PENNSYLVANIA | No |
| 7 | 3245S0500X | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 077009 | PENNSYLVANIA | No |
| 8 | 101YA0400X | Counselor | Addiction (Substance Use Disorder) | 077009 | PENNSYLVANIA | No |
| 9 | 320600000X | Residential Treatment Facility, Intellectual and/or Developmental Disabilities | | 077009 | PENNSYLVANIA | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 1007567870023 | MEDICAID | PENNSYLVANIA | |
