=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396347472
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRST RESPONDER COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2020
-----------------------------------------------------
Last Update Date | 11/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10028 W REDBIRD RD
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85383-3368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-259-3104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20403 N LAKE PLEASANT RD STE 117-268
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85382-9702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-259-3104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MENTAL HEALTH COUNSELOR
-----------------------------------------------------
Name | BERNADETTE BRUHA
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 505-259-3104
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------