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General NPI Number Information
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NPI Number | 1760810998
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Entity Type | Organization
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Legal Business Name | COUNSELING SERVICES OF MARIPOSA
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Dates
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Enumeration Date | 10/25/2013
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Last Update Date | 03/15/2014
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Provider Practice Location Address
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Address Line | 5078 BULLION ST.
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City | MARIPOSA
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State | CA
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Zip | 95338
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Country | US
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Telephone | 209-966-7035
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Fax |
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Provider Business Mailing Address
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Address Line | 5072 ALLRED RD
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City | MARIPOSA
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State | CA
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Zip | 95338-9705
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Country | US
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Telephone | 209-966-7035
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. ROBERT DALE BURTCH
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Credential | LCSW
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Telephone | 209-966-7035
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LCS29794
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License Number State | CA
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