Provider Demographics
NPI:1720143555
Name:PROFESSIONAL COUNSELING ASSOCIATES, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL COUNSELING ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:BAISDEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:304-235-3390
Mailing Address - Street 1:41 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-3201
Mailing Address - Country:US
Mailing Address - Phone:304-235-3390
Mailing Address - Fax:304-235-3391
Practice Address - Street 1:41 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3201
Practice Address - Country:US
Practice Address - Phone:304-235-3390
Practice Address - Fax:304-235-3391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV538101Y00000X
WV403103T00000X
WVCP004526691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810007784Medicaid
062399OtherVALUE OPTIONS
WV0163475000Medicaid
WV1558361527Medicare PIN
WV3810007826Medicaid