Provider Demographics
NPI:1174755078
Name:DEITRICK, MARK WILLIAM (LPC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:DEITRICK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2703 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101-8671
Mailing Address - Country:US
Mailing Address - Phone:724-657-3303
Mailing Address - Fax:724-657-3326
Practice Address - Street 1:229 PORTERSVILLE RD
Practice Address - Street 2:
Practice Address - City:ELLWOOD CITY
Practice Address - State:PA
Practice Address - Zip Code:16117-2431
Practice Address - Country:US
Practice Address - Phone:724-752-9114
Practice Address - Fax:724-657-3326
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC000115101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA251830792OtherINTERGROUP SERVICES CORPORATION
PA2114493OtherHIGHMARK BLUE CROSS BLUE SHEILD
12765444OtherMULTIPLAN