=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013518745
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKE SIMPSON LCMHCA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2020
-----------------------------------------------------
Last Update Date | 11/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 COASTAL HORIZONS DR
-----------------------------------------------------
City | SHALLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28470-6094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-754-4515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 217 HAWTHORNE AVE
-----------------------------------------------------
City | SWANNANOA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28778-2421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-778-5443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | A16112
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------