Healthcare Provider Details

I. General information

NPI: 1598397630
Provider Name (Legal Business Name): MOUNTAIN STATE COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 HARPER RD STE 200
BECKLEY WV
25801-3376
US

IV. Provider business mailing address

1802 HARPER RD STE 200
BECKLEY WV
25801-3376
US

V. Phone/Fax

Practice location:
  • Phone: 304-252-9211
  • Fax:
Mailing address:
  • Phone: 681-238-5733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTY SPADE
Title or Position: CEO
Credential:
Phone: 304-252-9211