Provider Demographics
NPI:1578986717
Name:FOOTPRINTS COUNSELING, PLLC
Entity Type:Organization
Organization Name:FOOTPRINTS COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:336-893-8727
Mailing Address - Street 1:3410 HEALY DR
Mailing Address - Street 2:SUITE 200-A
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1403
Mailing Address - Country:US
Mailing Address - Phone:336-893-8727
Mailing Address - Fax:336-893-8726
Practice Address - Street 1:3410 HEALY DR
Practice Address - Street 2:SUITE 200-A
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1403
Practice Address - Country:US
Practice Address - Phone:336-893-8727
Practice Address - Fax:336-893-8726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1184106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106255Medicaid