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General NPI Number Information
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NPI Number | 1184940751
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Entity Type | Organization
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Legal Business Name | COUNTRY-SIDE COUNSELING & CONSULTATION SERVICES, PC
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Dates
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Enumeration Date | 04/08/2010
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Last Update Date | 10/27/2016
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Provider Practice Location Address
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Address Line | 388 N 3RD AVE SUITE F
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City | FRUITPORT
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State | MI
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Zip | 49415-9785
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Country | US
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Telephone | 231-571-0082
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Fax |
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Provider Business Mailing Address
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Address Line | 388 N 3RD AVE SUITE F
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City | FRUITPORT
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State | MI
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Zip | 49415-9785
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Country | US
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Telephone | 231-571-0082
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. ROGER DALE BAYNE
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Credential | L.P.C
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Telephone | 231-571-0082
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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