1093118218 NPI number — PROFESSIONAL CARE COUNSELING SERVICE

Table of content: (NPI 1093118218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093118218 NPI number — PROFESSIONAL CARE COUNSELING SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL CARE COUNSELING SERVICE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093118218
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 S CEDAR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68801-6582
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-370-1667
Provider Business Mailing Address Fax Number:
402-298-2523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 S CEDAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68801-6582
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-370-1667
Provider Business Practice Location Address Fax Number:
402-298-2523
Provider Enumeration Date:
10/01/2014

Additional Information

Authorized Official

Authorized Official Last Name:
FLOREZ
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
BRIAN
Authorized Official Title or Position:
OUTPATIENT THERAPIST
Authorized Official Telephone Number:
308-370-1667

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  P-1145 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X , with the licence number: 10016 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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