Provider Demographics
NPI:1194875682
Name:GOODWILL INDUSTRIES OF FAYETTE COUNTY
Entity type:Organization
Organization Name:GOODWILL INDUSTRIES OF FAYETTE COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF AFFILIATE OPERATI
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-437-9878
Mailing Address - Street 1:44 CONNELLSVILLE STREET
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401
Mailing Address - Country:US
Mailing Address - Phone:724-437-9878
Mailing Address - Fax:724-437-9865
Practice Address - Street 1:690 W MAIN ST
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-2648
Practice Address - Country:US
Practice Address - Phone:724-439-9311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA416340251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA472028OtherVALUEOPTIONS PROVIDER NUM