=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598752370
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROSSROADS COUNSELING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2005
-----------------------------------------------------
Last Update Date | 07/10/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 N UNION AVE SUITE G
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88201-3068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-624-0486
-----------------------------------------------------
Fax | 505-624-3210
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 N UNION AVE SUITE G
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88201-3068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-624-0486
-----------------------------------------------------
Fax | 505-624-3210
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PROVIDER
-----------------------------------------------------
Name | KATHLEEN FREEBIRD
-----------------------------------------------------
Credential | LISW
-----------------------------------------------------
Telephone | 505-624-0486
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I-04800
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------