MEDICARE: CORNERSTONE COUNSELING LLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1629632773
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNERSTONE COUNSELING LLC

Provider Business Mailing Address
First Line	:	4601 E DOUGLAS AVE
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67218-1011
Country	:	US
Telephone Number	:	316-992-4978
Fax Number	:

Provider Business Practice Location Address
First Line	:	4601 E DOUGLAS AVE
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67218-1011
Country	:	US
Telephone Number	:	316-992-4978
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	IRMA JEFFRIES
Credential	:	LSCSW
Telephone Number	:	316-992-4978

Provider Enumeration Date	:	04/24/2019
Last Update Date	:	04/24/2019

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