MEDICARE: CROSSROADS COUNSELING, INC.

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	1041C0700X	Clinical Social Worker	I-04800	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	66935	OTHER		PRESBYTERIAN HEALTH CARE
3	NM00RE39	OTHER	NM	BLUE CROSS BLUE SHIELD
4	NM102138	OTHER	NM	VALUE OPTIONS

General Provider Information

NPI Number	:	1598752370
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROSSROADS COUNSELING, INC.

Provider Business Mailing Address
First Line	:	207 N UNION AVE
Second Line	:	SUITE G
City	:	ROSWELL
State	:	NM
Zip	:	88201-3068
Country	:	US
Telephone Number	:	505-624-0486
Fax Number	:	505-624-3210

Provider Business Practice Location Address
First Line	:	207 N UNION AVE
Second Line	:	SUITE G
City	:	ROSWELL
State	:	NM
Zip	:	88201-3068
Country	:	US
Telephone Number	:	505-624-0486
Fax Number	:	505-624-3210

Authorized Official
Title or Position	:	OWNER, PROVIDER
Name	:	KATHLEEN FREEBIRD
Credential	:	LISW
Telephone Number	:	505-624-0486

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	07/10/2007

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Directions to “CROSSROADS COUNSELING, INC. ” Practice Location

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