MEDICARE: SAN JUAN HOUSE COUNSELING CENTER

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	1851	CO
2	101YM0800X	Mental Health Counselor	2839	CO

General Provider Information

NPI Number	:	1477959617
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN JUAN HOUSE COUNSELING CENTER

Provider Business Mailing Address
First Line	:	309 SAN JUAN AVENUE
Second Line	:
City	:	ALAMOSA
State	:	CO
Zip	:	81101-3125
Country	:	US
Telephone Number	:	719-589-0202
Fax Number	:

Provider Business Practice Location Address
First Line	:	309 SAN JUAN AVE
Second Line	:
City	:	ALAMOSA
State	:	CO
Zip	:	81101-2534
Country	:	US
Telephone Number	:	719-589-0202
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	CASEY J GARCIA
Credential	:
Telephone Number	:	719-588-6777

Provider Enumeration Date	:	11/17/2014
Last Update Date	:	11/17/2014

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