Provider Demographics
NPI:1922687573
Name:WIDE OPEN COUNSELING LLC
Entity Type:Organization
Organization Name:WIDE OPEN COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARNELL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:915-777-8118
Mailing Address - Street 1:PO BOX 1992
Mailing Address - Street 2:
Mailing Address - City:MESILLA PARK
Mailing Address - State:NM
Mailing Address - Zip Code:88047-1992
Mailing Address - Country:US
Mailing Address - Phone:575-805-6288
Mailing Address - Fax:
Practice Address - Street 1:1685 S DON ROSER DR STE D
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4586
Practice Address - Country:US
Practice Address - Phone:575-805-6288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-02
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMX-11858OtherPROVISIONAL CLINICAL SOCIAL WORKER
1851979256OtherNPI