1487022083 NPI number — CROSSROADS COUNSELING SERVICES PC

Table of content: (NPI 1487022083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487022083 NPI number — CROSSROADS COUNSELING SERVICES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROSSROADS COUNSELING SERVICES PC
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:
1487022083
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2121 N WEBB RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68803-1751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-384-7119
Provider Business Mailing Address Fax Number:
308-384-7119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2121 N WEBB RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68803-1751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-384-7119
Provider Business Practice Location Address Fax Number:
308-384-7119
Provider Enumeration Date:
09/13/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CHARRON
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
OWNER, CEO
Authorized Official Telephone Number:
308-384-7119

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LIMHP # 89 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100254520-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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