Basic Information
| Provider Information | |||||||||
| NPI: | 1215007083 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST COUNSELING SERVICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829015610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073526680 | ||||||||
| FaxNumber: | 3073526614 | ||||||||
| Practice Location | |||||||||
| Address1: | 1124 COLLEGE DR | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829015863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073526677 | ||||||||
| FaxNumber: | 3073526614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 09/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | ACKER | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3073526680 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 324500000X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1061151-00 | 05 | WY | MEDICAID |