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General NPI Number Information
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NPI Number | 1134668841
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Entity Type | Organization
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Legal Business Name | AZPEN COUNSELING & SERVICES, LLC
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Dates
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Enumeration Date | 02/14/2017
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Last Update Date | 04/27/2019
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Provider Practice Location Address
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Address Line | 1930 MESQUITE AVE #1A
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403
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Country | US
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Telephone | 928-855-4900
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Fax | 928-855-4902
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Provider Business Mailing Address
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Address Line | 1930 MESQUITE AVE #1A
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403
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Country | US
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Telephone | 928-855-4900
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Fax | 928-855-4902
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Authorized Official
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Title or Position | OWNER/LICENSED PROFESSIONAL COUNSEL
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Name | MOLLY PORT
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Credential | LPC, NCC
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Telephone | 928-855-4900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 16468
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License Number State | AZ
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