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115 W Railway St Ste A102 Scottsbluff NE 69361-3180 | |
| (308) 225-0500 | |
| (308) 365-6848 |
| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 115 W Railway St Ste A102, Scottsbluff, Nebraska |
| Authorized Official Name and Position | Samuel Crouch (OWNER) |
| Authorized Official Contact | 3082250500 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
115 W Railway St Ste A102 Scottsbluff NE 69361-3180 Ph: (308) 225-0500 | 115 W Railway St Ste A102 Scottsbluff NE 69361-3180 Ph: (308) 225-0500 |
| NPI Number | 1215402151 |
|---|---|
| Provider Enumeration Date | 10/08/2018 |
| Last Update Date | 01/08/2024 |
| Certification Date | 01/08/2024 |
| Medicare PECOS PAC ID | 3274066162 |
|---|---|
| Medicare Enrollment ID | O20241030004106 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1215402151 | NPI | - | NPPES |
| 53611285605 | Medicaid | NE | |
| 10026769300 | Medicaid | NE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | (* (Not Available)) | Secondary |
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| Provider Name | Samuel William Crouch |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1619452943 PECOS PAC ID: 4183157076 Enrollment ID: I20241030004183 |
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