Provider Demographics
NPI:1770201675
Name:SELF-ALIGNMENT EVALUATION AND OUTPATIENT TREATMENT SERVICES, LLC
Entity type:Organization
Organization Name:SELF-ALIGNMENT EVALUATION AND OUTPATIENT TREATMENT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, (T)LMHC, IADC
Authorized Official - Phone:515-865-7783
Mailing Address - Street 1:100 E EUCLID AVE STE 157
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50313-4583
Mailing Address - Country:US
Mailing Address - Phone:515-868-1818
Mailing Address - Fax:
Practice Address - Street 1:100 E EUCLID AVE STE 157
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50313-4583
Practice Address - Country:US
Practice Address - Phone:515-868-1818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA284UU5368OtherDRIVER'S LICENSE NUMBER