MEDICARE: ST JOSEPH COUNSELING & REHABILITATION SERVICES, INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	103TR0400X	Rehabilitation Psychologist
3	101Y00000X	Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710251012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST JOSEPH COUNSELING & REHABILITATION SERVICES, INC

Provider Business Mailing Address
First Line	:	3334 S SW LOOP 323
Second Line	:	SUITE 108
City	:	TYLER
State	:	TX
Zip	:	75701-9237
Country	:	US
Telephone Number	:	903-581-7973
Fax Number	:	903-581-6605

Provider Business Practice Location Address
First Line	:	3334 S SW LOOP 323
Second Line	:	SUITE 108
City	:	TYLER
State	:	TX
Zip	:	75701-9237
Country	:	US
Telephone Number	:	903-581-7973
Fax Number	:	903-581-6605

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KEN A CHINWEZE
Credential	:
Telephone Number	:	903-581-7973

Provider Enumeration Date	:	03/05/2012
Last Update Date	:	04/16/2012

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