Provider Demographics
NPI:1679598924
Name:STOLTZ, MARK ALAN (LCSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:STOLTZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-375-6379
Mailing Address - Fax:814-375-9320
Practice Address - Street 1:635 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2376
Practice Address - Country:US
Practice Address - Phone:814-375-6379
Practice Address - Fax:814-375-9320
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW014010104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA058095HSUMedicare ID - Type Unspecified