=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043922909
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIA COUNSELING RESOURCES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2022
-----------------------------------------------------
Last Update Date | 12/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 N OCOEE ST STE 220
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37311-5030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-544-9167
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5255 HOWARDSVILLE RD
-----------------------------------------------------
City | APISON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37302-9738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-544-9167
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CLINICAL COUNSELOR
-----------------------------------------------------
Name | LUTHER CAMPBELL
-----------------------------------------------------
Credential | LPC-MHSP
-----------------------------------------------------
Telephone | 224-544-9167
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------