Provider Demographics
NPI:1760051825
Name:ICU COUNSELING AND MENTAL HEALTH SUPPORT SERVICES, LLC
Entity Type:Organization
Organization Name:ICU COUNSELING AND MENTAL HEALTH SUPPORT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEMETRIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-545-9659
Mailing Address - Street 1:PO BOX 40123
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0123
Mailing Address - Country:US
Mailing Address - Phone:251-545-9659
Mailing Address - Fax:
Practice Address - Street 1:114 ESPLANADE AVE
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-5057
Practice Address - Country:US
Practice Address - Phone:251-545-9659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-23
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty