1275354664 NPI number — IMAGO LIFE COUNSELING, LLC

Table of content: MR. DENNIS LEE STEVENS BC-HIS (NPI 1063637148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275354664 NPI number — IMAGO LIFE COUNSELING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMAGO LIFE COUNSELING, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275354664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 S PROGRESS AVE STE 3A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRISBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17109-4636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-602-9023
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8237 THOURON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19150-2018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-602-9023
Provider Business Practice Location Address Fax Number:
902-216-8269
Provider Enumeration Date:
10/18/2024

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
ROSANNE
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER/THERAPIST
Authorized Official Telephone Number:
717-602-9023

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PC001128 . This is a "PA LPC LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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