Provider Demographics
NPI:1417597683
Name:A VICTORS GATHERING COUNSELING SERVICE
Entity type:Organization
Organization Name:A VICTORS GATHERING COUNSELING SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-596-4129
Mailing Address - Street 1:417 E VEATCH ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3570
Mailing Address - Country:US
Mailing Address - Phone:208-874-7989
Mailing Address - Fax:
Practice Address - Street 1:417 E VEATCH ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3570
Practice Address - Country:US
Practice Address - Phone:208-874-7989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-15
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty