Provider Demographics
NPI:1417370131
Name:PROFESSIONAL COUNSELING ASSOCIATES
Entity Type:Organization
Organization Name:PROFESSIONAL COUNSELING ASSOCIATES
Other - Org Name:GSRCOA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:OAKES
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:575-472-5383
Mailing Address - Street 1:419 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:TUCUMCARI
Mailing Address - State:NM
Mailing Address - Zip Code:88401-2859
Mailing Address - Country:US
Mailing Address - Phone:575-472-5383
Mailing Address - Fax:575-472-5384
Practice Address - Street 1:419 S 2ND ST
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-2859
Practice Address - Country:US
Practice Address - Phone:575-472-5383
Practice Address - Fax:575-472-5384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-04593261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)