Healthcare Provider Details

I. General information

NPI: 1710270087
Provider Name (Legal Business Name): FULL CIRCLE THERAPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 3RD AVE
COUNCIL BLUFFS IA
51501
US

IV. Provider business mailing address

803 3RD AVE
COUNCIL BLUFFS IA
51501
US

V. Phone/Fax

Practice location:
  • Phone: 402-210-6507
  • Fax:
Mailing address:
  • Phone: 402-210-6507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001148
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KAMI GUZMAN
Title or Position: CO-OWNER
Credential:
Phone: 712-352-0917