Provider Demographics
NPI:1467034058
Name:IMPACT ME ADDICTION COUNSELING SERVICES
Entity Type:Organization
Organization Name:IMPACT ME ADDICTION COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SERI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:681-265-1140
Mailing Address - Street 1:303 WASHINGTON ST W STE 205
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-2230
Mailing Address - Country:US
Mailing Address - Phone:681-265-1140
Mailing Address - Fax:
Practice Address - Street 1:303 WASHINGTON ST W STE 205
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-2230
Practice Address - Country:US
Practice Address - Phone:681-265-1140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-23
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251K00000XAgenciesPublic Health or Welfare
No305S00000XManaged Care OrganizationsPoint of Service