Provider Demographics
NPI:1376522060
Name:BETHESDA CHRISTIAN COUNSELING MIDWEST, INC.
Entity Type:Organization
Organization Name:BETHESDA CHRISTIAN COUNSELING MIDWEST, INC.
Other - Org Name:BETHESDA CHRISTIAN COUNSELING MIDWEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:EETEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-334-3739
Mailing Address - Street 1:400 S SYCAMORE AVE
Mailing Address - Street 2:SUITE 105-3
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-1246
Mailing Address - Country:US
Mailing Address - Phone:605-334-3739
Mailing Address - Fax:605-334-4775
Practice Address - Street 1:400 S SYCAMORE AVE STE 105-3
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-1255
Practice Address - Country:US
Practice Address - Phone:605-334-3739
Practice Address - Fax:605-334-7752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00291101Y00000X
IA001072101YM0800X
IA001696101YM0800X
SD7288101YP2500X
MNLP2939103T00000X
SD446103T00000X
SD673104100000X
SD947104100000X
IA06042104100000X
IA0850161041C0700X
SD0864711041C0700X
SD20802084P0800X
IA270592084P0800X
261QM0801X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD28524BEOtherBC BS OF MINNESOTA
SD0004414OtherBC BS OF SOUTH DAKOTA
IA=========Medicaid
SDS4414Medicare PIN
IA70005Medicare PIN