Healthcare Provider Details

I. General information

NPI: 1790222370
Provider Name (Legal Business Name): TRANSITIONAL LIFE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2017
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 XENIA AVE
YELLOW SPRINGS OH
45387-1123
US

IV. Provider business mailing address

1525 XENIA AVE
YELLOW SPRINGS OH
45387-1123
US

V. Phone/Fax

Practice location:
  • Phone: 937-769-5019
  • Fax: 937-769-5019
Mailing address:
  • Phone: 937-769-5019
  • Fax: 937-769-5019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE0600045
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6323
License Number StateOH

VIII. Authorized Official

Name: DR. ROSE MARY SHAW
Title or Position: CLINICAL PSYCHOLOGIST/OWNER
Credential: PSYD
Phone: 937-769-5019