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General NPI Number Information
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NPI Number | 1760051825
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Entity Type | Organization
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Legal Business Name | ICU COUNSELING AND MENTAL HEALTH SUPPORT SERVICES, LLC
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Dates
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Enumeration Date | 06/23/2021
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Last Update Date | 01/08/2025
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Provider Practice Location Address
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Address Line | 3351 MOFFETT RD
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City | MOBILE
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State | AL
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Zip | 36607-1713
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Country | US
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Telephone | 251-423-4014
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Fax |
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Provider Business Mailing Address
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Address Line | 350 STUDENT CENTER CIR U3715
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City | MOBILE
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State | AL
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Zip | 36688-0001
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Country | US
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Telephone | 251-545-9659
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DEMETRIUS SMITH
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Credential |
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Telephone | 251-545-9659
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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