Provider Demographics
NPI:1174729990
Name:DELUCA FAMILY WELLNESS CENTER, INC.
Entity type:Organization
Organization Name:DELUCA FAMILY WELLNESS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DELUCA
Authorized Official - Suffix:
Authorized Official - Credentials:MS , LPC
Authorized Official - Phone:304-626-3541
Mailing Address - Street 1:RT. 2 BOX 406 SUITE 121
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301
Mailing Address - Country:US
Mailing Address - Phone:304-626-3541
Mailing Address - Fax:304-626-3174
Practice Address - Street 1:RT. 2 BOX 406 SUITE 121
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301
Practice Address - Country:US
Practice Address - Phone:304-626-3541
Practice Address - Fax:304-626-3174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2008-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1540101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1540OtherWV LPC