Provider Demographics
NPI: | 1760735864 |
---|---|
Name: | MICHAEL BRUBAKER COUNSELING |
Entity Type: | Organization |
Organization Name: | MICHAEL BRUBAKER COUNSELING |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | MICHAEL |
Authorized Official - Middle Name: | C |
Authorized Official - Last Name: | BRUBAKER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LISAC, NCGC II |
Authorized Official - Phone: | 520-836-9788 |
Mailing Address - Street 1: | 1927 N TREKELL RD STE D |
Mailing Address - Street 2: | |
Mailing Address - City: | CASA GRANDE |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85122-1762 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 520-836-9788 |
Mailing Address - Fax: | 520-421-1975 |
Practice Address - Street 1: | 1927 N TREKELL RD STE D |
Practice Address - Street 2: | |
Practice Address - City: | CASA GRANDE |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85122-1762 |
Practice Address - Country: | US |
Practice Address - Phone: | 520-836-9788 |
Practice Address - Fax: | 520-421-1975 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-10-26 |
Last Update Date: | 2012-10-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | BH-3333 | 251S00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251S00000X | Agencies | Community/Behavioral Health |