=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598357261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILD AND FAMILY GUIDANCE AND SUPPORT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2021
-----------------------------------------------------
Last Update Date | 02/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 N BOULEVARD ST STE 203
-----------------------------------------------------
City | GUNNISON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81230-3011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-381-2543
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 N BOULEVARD ST STE 203
-----------------------------------------------------
City | GUNNISON
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81230-3011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-381-2543
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MENTAL HEALTH COUNSELOR
-----------------------------------------------------
Name | KRISTIN A COUGHLIN
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 720-381-2543
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------