Healthcare Provider Details

I. General information

NPI: 1619373099
Provider Name (Legal Business Name): CHAMBERLAIN COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79321 DIAMONDHEAD DR E
DIAMONDHEAD MS
39525-3544
US

IV. Provider business mailing address

79321 DIAMONDHEAD DR E
DIAMONDHEAD MS
39525-3544
US

V. Phone/Fax

Practice location:
  • Phone: 601-850-8663
  • Fax:
Mailing address:
  • Phone: 601-850-8663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1548
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-11-9380
License Number State

VIII. Authorized Official

Name: MR. WALTER G CHAMBERLAIN JR.
Title or Position: CEO
Credential: M.ED, LPC-S, BCBA
Phone: 604-850-8663