Provider Demographics
NPI:1447519053
Name:PHASE TWO COUNSELING SERVICE
Entity type:Organization
Organization Name:PHASE TWO COUNSELING SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DRIECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARGIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:JONES-DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCBT, CAC III
Authorized Official - Phone:719-473-1805
Mailing Address - Street 1:2019 E BIJOU ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5818
Mailing Address - Country:US
Mailing Address - Phone:719-473-1805
Mailing Address - Fax:719-302-5324
Practice Address - Street 1:2019 E BIJOU ST
Practice Address - Street 2:SUITE #1
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5818
Practice Address - Country:US
Practice Address - Phone:719-473-1805
Practice Address - Fax:719-302-5324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6148101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO141948Medicaid