MEDICARE: FAMILY COUNSELING SERVICE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	340030066A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000574840	OTHER	IN	ANTHEM BLUE CROSS AND BLUE SHIELD

General Provider Information

NPI Number	:	1235389321
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY COUNSELING SERVICE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 182
Second Line	:
City	:	NEWBURGH
State	:	IN
Zip	:	47629-0182
Country	:	US
Telephone Number	:	812-897-7131
Fax Number	:	812-897-7456

Provider Business Practice Location Address
First Line	:	1116 MILLIS AVE
Second Line	:
City	:	BOONVILLE
State	:	IN
Zip	:	47601-2226
Country	:	US
Telephone Number	:	812-897-7131
Fax Number	:	812-897-7456

Authorized Official
Title or Position	:	THERAPIST
Name	:	MR. ALLEN MONROE TOY II
Credential	:	LCSW
Telephone Number	:	812-897-7131

Provider Enumeration Date	:	09/24/2008
Last Update Date	:	09/24/2008

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