Provider Demographics
NPI:1225403637
Name:PROFESSIONAL BEHAVIORAL HEALTH SERVICES OF ST. MICHAELS
Entity Type:Organization
Organization Name:PROFESSIONAL BEHAVIORAL HEALTH SERVICES OF ST. MICHAELS
Other - Org Name:PROFESSIONAL COUNSELING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:
Authorized Official - Last Name:JIM
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:928-871-5409
Mailing Address - Street 1:LOT 165 BLANCO ROAD
Mailing Address - Street 2:KARIGAN ESTATES
Mailing Address - City:SAINT MICHAELS
Mailing Address - State:AZ
Mailing Address - Zip Code:86511-0645
Mailing Address - Country:US
Mailing Address - Phone:928-871-5409
Mailing Address - Fax:
Practice Address - Street 1:LOT 165 BLANCO RD
Practice Address - Street 2:
Practice Address - City:SAINT MICHAELS
Practice Address - State:AZ
Practice Address - Zip Code:86511-0645
Practice Address - Country:US
Practice Address - Phone:928-871-5409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0146941101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty