Provider Demographics
NPI:1114467552
Name:PATRIOT COUNSELING SERVICES
Entity type:Organization
Organization Name:PATRIOT COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF AGENCY AND TREATMENT P
Authorized Official - Prefix:
Authorized Official - First Name:CHARLA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CATC IV, MAC, SA
Authorized Official - Phone:775-848-9771
Mailing Address - Street 1:165 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:PORTOLA
Mailing Address - State:CA
Mailing Address - Zip Code:96122-8609
Mailing Address - Country:US
Mailing Address - Phone:775-848-9771
Mailing Address - Fax:
Practice Address - Street 1:545 W SIERRA ST
Practice Address - Street 2:
Practice Address - City:PORTOLA
Practice Address - State:CA
Practice Address - Zip Code:96122-8615
Practice Address - Country:US
Practice Address - Phone:775-848-9771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-05
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health