Provider Demographics
NPI:1710251012
Name:ST JOSEPH COUNSELING & REHABILITATION SERVICES, INC
Entity Type:Organization
Organization Name:ST JOSEPH COUNSELING & REHABILITATION SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHINWEZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-581-7973
Mailing Address - Street 1:3334 S SW LOOP 323
Mailing Address - Street 2:SUITE 108
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-9237
Mailing Address - Country:US
Mailing Address - Phone:903-581-7973
Mailing Address - Fax:903-581-6605
Practice Address - Street 1:3334 S SW LOOP 323
Practice Address - Street 2:SUITE 108
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9237
Practice Address - Country:US
Practice Address - Phone:903-581-7973
Practice Address - Fax:903-581-6605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-05
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1194941518Medicaid