Provider Demographics
NPI: | 1659702405 |
---|---|
Name: | INNER JOURNEY COUNSELING PC |
Entity Type: | Organization |
Organization Name: | INNER JOURNEY COUNSELING PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | RON |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | PAUL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LCSW |
Authorized Official - Phone: | 928-380-6130 |
Mailing Address - Street 1: | 711 N BEAVER ST |
Mailing Address - Street 2: | |
Mailing Address - City: | FLAGSTAFF |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 86001-3103 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 928-380-6130 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 711 N BEAVER ST |
Practice Address - Street 2: | |
Practice Address - City: | FLAGSTAFF |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 86001-3103 |
Practice Address - Country: | US |
Practice Address - Phone: | 928-380-6130 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2013-12-04 |
Last Update Date: | 2013-12-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | LCSW-13675 | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Single Specialty |