Healthcare Provider Details

I. General information

NPI: 1629013065
Provider Name (Legal Business Name): GOOD SAMARITAN COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 12/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4241 B ST SUITE 100
ANCHORAGE AK
99503-5920
US

IV. Provider business mailing address

2530 DEBARR RD
ANCHORAGE AK
99508-2996
US

V. Phone/Fax

Practice location:
  • Phone: 907-565-4000
  • Fax: 907-565-4011
Mailing address:
  • Phone: 907-264-3595
  • Fax: 907-264-3515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number435
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2817
License Number StateAK
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number54965
License Number StateAK
# 9
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICHELE FISSORI
Title or Position: CFO
Credential:
Phone: 907-264-3525