Provider Demographics
NPI:1104100833
Name:COUNTRYSIDE COUNSELING CENTER, LLC
Entity type:Organization
Organization Name:COUNTRYSIDE COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HASTINGS
Authorized Official - Suffix:
Authorized Official - Credentials:LCP, LMLP, LCAC
Authorized Official - Phone:620-577-4955
Mailing Address - Street 1:601 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KS
Mailing Address - Zip Code:67301-1932
Mailing Address - Country:US
Mailing Address - Phone:620-577-4955
Mailing Address - Fax:620-577-4956
Practice Address - Street 1:601 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301-1932
Practice Address - Country:US
Practice Address - Phone:620-577-4955
Practice Address - Fax:620-577-4956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS103T00000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200432330CMedicaid