Basic Information
| Provider Information | |||||||||
| NPI: | 1588932503 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBUS STATE UNIVERSITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CSU - THE COUNSELING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 168007 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750168007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4697354555 | ||||||||
| FaxNumber: | 4697354640 | ||||||||
| Practice Location | |||||||||
| Address1: | 4225 UNIVERSITY AVE | ||||||||
| Address2: | SCHUSTER CENTER | ||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319075679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065078740 | ||||||||
| FaxNumber: | 7065078753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2011 | ||||||||
| LastUpdateDate: | 12/05/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4697354555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPMSM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.