Provider Demographics
NPI:1205223328
Name:INDENPENDENT CONTRACTOR FOR COUNSELING SERVICES
Entity Type:Organization
Organization Name:INDENPENDENT CONTRACTOR FOR COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE PROPRIETATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:M
Authorized Official - Last Name:SANCHEZ-RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:850-814-5060
Mailing Address - Street 1:608 SOMMER CIR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3224
Mailing Address - Country:US
Mailing Address - Phone:850-814-5060
Mailing Address - Fax:850-265-1811
Practice Address - Street 1:1606 TENNESSEE AVE
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-3653
Practice Address - Country:US
Practice Address - Phone:850-814-5060
Practice Address - Fax:850-265-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4860101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL763657100Medicaid
FL811551600OtherMEDICAID- DEVELOPMENTAL SPECIALIST