Provider Demographics
NPI:1184940751
Name:COUNTRY-SIDE COUNSELING & CONSULTATION SERVICES, PC
Entity type:Organization
Organization Name:COUNTRY-SIDE COUNSELING & CONSULTATION SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:BAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:231-571-0082
Mailing Address - Street 1:388 N 3RD AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:FRUITPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49415-9785
Mailing Address - Country:US
Mailing Address - Phone:231-571-0082
Mailing Address - Fax:
Practice Address - Street 1:388 N 3RD AVE
Practice Address - Street 2:SUITE F
Practice Address - City:FRUITPORT
Practice Address - State:MI
Practice Address - Zip Code:49415-9785
Practice Address - Country:US
Practice Address - Phone:231-571-0082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty