1649718305 NPI number — TARYN PETERSEN MA, LPC, NCC

Table of content: TARYN PETERSEN MA, LPC, NCC (NPI 1649718305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649718305 NPI number — TARYN PETERSEN MA, LPC, NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
TARYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC, NCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SOLT
Provider Other First Name:
TARYN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649718305
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 288
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STROUDSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18360-0288
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-620-4311
Provider Business Mailing Address Fax Number:
570-620-4332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 TERRACE DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
STROUDSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18360-7510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-620-4311
Provider Business Practice Location Address Fax Number:
570-620-4332
Provider Enumeration Date:
02/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  PC009331 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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