Provider Demographics
NPI:1508473141
Name:INTERCESSORY COUNSELING AND CONSULTING OUTREACH INC
Entity Type:Organization
Organization Name:INTERCESSORY COUNSELING AND CONSULTING OUTREACH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-415-5715
Mailing Address - Street 1:1113B JEFFERSON RD
Mailing Address - Street 2:
Mailing Address - City:S CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-9780
Mailing Address - Country:US
Mailing Address - Phone:304-415-5715
Mailing Address - Fax:
Practice Address - Street 1:1113B JEFFERSON RD
Practice Address - Street 2:
Practice Address - City:S CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-9780
Practice Address - Country:US
Practice Address - Phone:304-415-5715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty