Provider Demographics
NPI:1609193002
Name:MAIN STREET COUNSELING CENTER, LLC
Entity Type:Organization
Organization Name:MAIN STREET COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:817-886-5777
Mailing Address - Street 1:621 N MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-9213
Mailing Address - Country:US
Mailing Address - Phone:817-886-5777
Mailing Address - Fax:817-421-1950
Practice Address - Street 1:621 N MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-9213
Practice Address - Country:US
Practice Address - Phone:817-886-5777
Practice Address - Fax:817-421-1950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX160441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX063955102Medicaid