=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013658608
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVERSE SUPPORT COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2022
-----------------------------------------------------
Last Update Date | 04/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 HIGH ST
-----------------------------------------------------
City | SOUTH RIVER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08882-1554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-473-5105
-----------------------------------------------------
Fax | 732-865-7283
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 HIGH ST
-----------------------------------------------------
City | SOUTH RIVER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08882-1554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-473-5105
-----------------------------------------------------
Fax | 732-865-7283
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SARAH BARKS
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 856-473-5105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------