Healthcare Provider Details

I. General information

NPI: 1043556897
Provider Name (Legal Business Name): EUBANK COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2012
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 W MAIN ST
FARMINGTON NM
87401-3220
US

IV. Provider business mailing address

2103 W MAIN ST
FARMINGTON NM
87401-3220
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-0264
  • Fax: 505-325-9035
Mailing address:
  • Phone: 505-327-0264
  • Fax: 505-325-9035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0095591
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0095601
License Number StateNM

VIII. Authorized Official

Name: MR. WILLIAM PAGE EUBANK
Title or Position: LICENSED PROF CLINICAL COUNSELOR
Credential: MA, LPCC
Phone: 505-327-0264