Provider Demographics
NPI:1003284514
Name:FOOTPRINTS COUNSELING SERVICES
Entity Type:Organization
Organization Name:FOOTPRINTS COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LOLETA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:909-283-0997
Mailing Address - Street 1:PO BOX 882
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-0882
Mailing Address - Country:US
Mailing Address - Phone:909-283-0997
Mailing Address - Fax:
Practice Address - Street 1:34455 YUCAIPA BLVD STE 206
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2476
Practice Address - Country:US
Practice Address - Phone:909-283-0997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49983106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty