Provider Demographics
NPI:1932168689
Name:CROSSROADS COUNSELING SERVICES
Entity Type:Organization
Organization Name:CROSSROADS COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST AND CO-OWNE
Authorized Official - Prefix:MS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:336-846-7492
Mailing Address - Street 1:PO BOX 212
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28640-0212
Mailing Address - Country:US
Mailing Address - Phone:336-846-7492
Mailing Address - Fax:336-846-7397
Practice Address - Street 1:224 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28640-9664
Practice Address - Country:US
Practice Address - Phone:336-846-7492
Practice Address - Fax:336-846-7397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3369101YM0800X
NCC003481101YM0800X
NC1903101YM0800X
NC3359101YM0800X
NC4955101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005268Medicaid
NC012T0OtherBLUE CROSS AND BLUE SHIEL
NC6005268Medicaid