Healthcare Provider Details

I. General information

NPI: 1093118218
Provider Name (Legal Business Name): PROFESSIONAL CARE COUNSELING SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S CEDAR ST
GRAND ISLAND NE
68801-6582
US

IV. Provider business mailing address

205 S CEDAR ST
GRAND ISLAND NE
68801-6582
US

V. Phone/Fax

Practice location:
  • Phone: 308-370-1667
  • Fax: 402-298-2523
Mailing address:
  • Phone: 308-370-1667
  • Fax: 402-298-2523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberP-1145
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10016
License Number StateNE

VIII. Authorized Official

Name: MR. THOMAS BRIAN FLOREZ
Title or Position: OUTPATIENT THERAPIST
Credential: PLMHP/PLADC
Phone: 308-370-1667