Provider Demographics
NPI:1922691104
Name:SECOND STORY COUSELING
Entity Type:Organization
Organization Name:SECOND STORY COUSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIMARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:480-688-8282
Mailing Address - Street 1:4320 E BROWN RD STE 105
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4081
Mailing Address - Country:US
Mailing Address - Phone:480-688-8282
Mailing Address - Fax:
Practice Address - Street 1:4320 E BROWN RD STE 105
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4081
Practice Address - Country:US
Practice Address - Phone:480-688-8282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)