=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023361888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANN-OPAL COUNSELING & CONSULTING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2012
-----------------------------------------------------
Last Update Date | 10/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1507 HARDY ST SUITE 104
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39401-4978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-336-6847
-----------------------------------------------------
Fax | 601-510-9403
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1507 HARDY ST SUITE 104
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39401-4978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | SHIRA PETERSON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 601-336-6847
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 1542
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------