Basic Information
| Provider Information | |||||||||
| NPI: | 1104862549 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR COUNSELING AND CONSULTATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5815 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207922544 | ||||||||
| FaxNumber: | 6207927052 | ||||||||
| Practice Location | |||||||||
| Address1: | 5815 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207922544 | ||||||||
| FaxNumber: | 6207927052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 05/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | STANG | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CLIN DIR | ||||||||
| AuthorizedOfficialTelephone: | 6207922544 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 004-06302011 | KS | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 100098090A | 05 | KS | MEDICAID |