Provider Demographics
NPI:1619373099
Name:CHAMBERLAIN COUNSELING SERVICES LLC
Entity Type:Organization
Organization Name:CHAMBERLAIN COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:G
Authorized Official - Last Name:CHAMBERLAIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MED, LPC-S, BCBA
Authorized Official - Phone:604-850-8663
Mailing Address - Street 1:79321 DIAMONDHEAD DR E
Mailing Address - Street 2:
Mailing Address - City:DIAMONDHEAD
Mailing Address - State:MS
Mailing Address - Zip Code:39525-3544
Mailing Address - Country:US
Mailing Address - Phone:601-850-8663
Mailing Address - Fax:
Practice Address - Street 1:79321 DIAMONDHEAD DR E
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3544
Practice Address - Country:US
Practice Address - Phone:601-850-8663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1548101YP2500X
1-11-9380103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty