MEDICARE: SOUTHWEST COUNSELING SERVICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1437994142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST COUNSELING SERVICE

Provider Business Mailing Address
First Line	:	2300 FOOTHILL BLVD
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-5610
Country	:	US
Telephone Number	:	307-352-6677
Fax Number	:	307-352-6614

Provider Business Practice Location Address
First Line	:	3416 WHITE MOUNTAIN BLVD
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4729
Country	:	US
Telephone Number	:	307-352-6677
Fax Number	:

Authorized Official
Title or Position	:	AR SUPERVISOR
Name	:	HEATHER GONZALEZ
Credential	:
Telephone Number	:	307-352-6677

Provider Enumeration Date	:	06/26/2024
Last Update Date	:	06/26/2024

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