MEDICARE: APPALACHIAN COUNSELING SERVICES, 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	0701004867	VA

General Provider Information

NPI Number	:	1871920991
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	APPALACHIAN COUNSELING SERVICES, INC

Provider Business Mailing Address
First Line	:	1015A LOVER'S GAP RIAD
Second Line	:
City	:	VANSANT
State	:	VA
Zip	:	24657
Country	:	US
Telephone Number	:	276-859-2129
Fax Number	:

Provider Business Practice Location Address
First Line	:	1034 FREEHOLD ROAD
Second Line	:
City	:	DAVENPORT
State	:	VA
Zip	:	24239
Country	:	US
Telephone Number	:	276-859-2129
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	KAREN BRADLEY-JACKSON
Credential	:	MS,LPC
Telephone Number	:	276-859-2129

Provider Enumeration Date	:	10/03/2013
Last Update Date	:	10/03/2013

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