Provider Demographics
NPI:1134668841
Name:AZPEN COUNSELING & SERVICES, LLC
Entity Type:Organization
Organization Name:AZPEN COUNSELING & SERVICES, LLC
Other - Org Name:MOLLY PORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/LICENSED PROFESSIONAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PORT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC
Authorized Official - Phone:928-855-4900
Mailing Address - Street 1:1930 MESQUITE AVE
Mailing Address - Street 2:#1A
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403
Mailing Address - Country:US
Mailing Address - Phone:928-855-4900
Mailing Address - Fax:928-855-4902
Practice Address - Street 1:1930 MESQUITE AVE
Practice Address - Street 2:#1A
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-855-4900
Practice Address - Fax:928-855-4902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-14
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16468251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health