Provider Demographics
NPI:1205081221
Name:PARKSIDE PSYCHOLOGICAL ASSOCIATES
Entity type:Organization
Organization Name:PARKSIDE PSYCHOLOGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:814-807-0861
Mailing Address - Street 1:435 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-4404
Mailing Address - Country:US
Mailing Address - Phone:814-807-0861
Mailing Address - Fax:814-807-0863
Practice Address - Street 1:435 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-4404
Practice Address - Country:US
Practice Address - Phone:814-807-0861
Practice Address - Fax:814-807-0863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA518561OtherVALUE OPTION
1316981590OtherNPI
1205081221OtherGROUP NPI
PA00182711Medicaid
PA1024120790006Medicaid
1306866959OtherNPI
PA462825OtherVALUE OPTIONS