Provider Demographics
NPI:1396027272
Name:PROFESSIONAL CONFIDENTIAL COUNSELING SERVICES LLC
Entity Type:Organization
Organization Name:PROFESSIONAL CONFIDENTIAL COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SWEENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-778-5151
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:VANDERWAGEN
Mailing Address - State:NM
Mailing Address - Zip Code:87326-0190
Mailing Address - Country:US
Mailing Address - Phone:505-778-5177
Mailing Address - Fax:505-778-5151
Practice Address - Street 1:103A SAGAR DRIVE
Practice Address - Street 2:
Practice Address - City:VANDERWAGEN
Practice Address - State:NM
Practice Address - Zip Code:87326
Practice Address - Country:US
Practice Address - Phone:505-778-5151
Practice Address - Fax:505-778-5151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-15
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0109351101YA0400X
NM0089971101YM0800X
NM0086791101YP2500X
NMI-055651041C0700X
NMI-27061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty