Provider Demographics
NPI:1699982348
Name:PRESCOTT COUNSELING AND CONSULTING, LTD
Entity type:Organization
Organization Name:PRESCOTT COUNSELING AND CONSULTING, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:DERESCHUK
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:928-774-3400
Mailing Address - Street 1:PO BOX 2456
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-2456
Mailing Address - Country:US
Mailing Address - Phone:928-774-3400
Mailing Address - Fax:
Practice Address - Street 1:1515 N SAN FRANCISCO ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1435
Practice Address - Country:US
Practice Address - Phone:928-774-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3096103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPHD3096Medicare ID - Type UnspecifiedMEDICARE ID