Basic Information
| Provider Information | |||||||||
| NPI: | 1003299397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATACKAS | ||||||||
| FirstName: | EUGENA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS LBS LPC NCC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | PATACKAS | ||||||||
| OtherFirstName: | GENA | ||||||||
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| OtherCredential: | MS LBS LPC NCC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 717 E PINE ST | ||||||||
| Address2: | |||||||||
| City: | OLYPHANT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184471934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706877495 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 106 COLBURN AVE | ||||||||
| Address2: | |||||||||
| City: | CLARKS SUMMIT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184111569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706877495 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2015 | ||||||||
| LastUpdateDate: | 11/04/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.