Healthcare Provider Details

I. General information

NPI: 1487900965
Provider Name (Legal Business Name): SEASONS CENTER FOR MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E 11TH ST
SPENCER IA
51301-4436
US

IV. Provider business mailing address

201 E 11TH ST
SPENCER IA
51301-4436
US

V. Phone/Fax

Practice location:
  • Phone: 800-242-5101
  • Fax: 712-264-3177
Mailing address:
  • Phone: 800-242-5101
  • Fax: 712-264-3177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number05041
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001530
License Number StateIA

VIII. Authorized Official

Name: MRS. BRENNA A. KOEDAM
Title or Position: SUBSTANCE ABUSE SERVICES SUPERVISOR
Credential: LMHC, IADC
Phone: 800-242-5101