Healthcare Provider Details

I. General information

NPI: 1790429652
Provider Name (Legal Business Name): JOURNEY COUNSELING CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 JENSON AVE SE
WATERTOWN SD
57201-5259
US

IV. Provider business mailing address

1103 JENSON AVE SE
WATERTOWN SD
57201-5259
US

V. Phone/Fax

Practice location:
  • Phone: 605-878-1234
  • Fax: 605-878-2211
Mailing address:
  • Phone: 605-878-1234
  • Fax: 605-878-2211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MARY KAY JOHNSON
Title or Position: CLINICAL THERAPIST
Credential: CSW-PIP
Phone: 605-881-0860