=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225043904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNSELING CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2006
-----------------------------------------------------
Last Update Date | 07/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 10TH ST
-----------------------------------------------------
City | ALAMOGORDO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88310-5053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-488-2500
-----------------------------------------------------
Fax | 575-488-2502
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 10TH ST
-----------------------------------------------------
City | ALAMOGORDO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88310-5053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-488-2500
-----------------------------------------------------
Fax | 575-488-2502
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | MR. LOREN E JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 575-488-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 3040B1
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------