Healthcare Provider Details

I. General information

NPI: 1184151946
Provider Name (Legal Business Name): INDIVIDUAL AND FAMILY COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 JACKSON BLVD # 198
RAPID CITY SD
57702-3474
US

IV. Provider business mailing address

2650 JACKSON BLVD # 198
RAPID CITY SD
57702-3474
US

V. Phone/Fax

Practice location:
  • Phone: 605-484-5294
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-MH2002
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1902886658
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name: JAMES SIMPSON
Title or Position: PROVIDER
Credential:
Phone: 605-484-5294