=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720484959
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMERICAN COUNSELING SERVICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2014
-----------------------------------------------------
Last Update Date | 11/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8888 DYER ST SUITE 419
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79904-2867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-886-8793
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8888 DYER ST SUITE 419
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79904-2867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-886-8793
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL KEITH WADE
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 915-886-8793
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 68877
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 68877
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------