1306316492 NPI number — NEW BEGINNINGS COUNSELING SERVICES, LLC

Table of content: MRS. STACY A. ITAGAKI MPT (NPI 1336211044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306316492 NPI number — NEW BEGINNINGS COUNSELING SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW BEGINNINGS COUNSELING SERVICES, LLC
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:
1306316492
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 CAROLYN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLEN CARBON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62034-1940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-744-0844
Provider Business Mailing Address Fax Number:
618-505-5044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
189 E US HIGHWAY 40 STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62294-2267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-744-0844
Provider Business Practice Location Address Fax Number:
618-505-5044
Provider Enumeration Date:
11/30/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SHELTON
Authorized Official First Name:
DIONA
Authorized Official Middle Name:
RANEE
Authorized Official Title or Position:
LICENSED CLINICAL SOCIAL WORKER
Authorized Official Telephone Number:
618-744-0844

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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