=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053180232
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKESIDE COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2023
-----------------------------------------------------
Last Update Date | 12/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1450 TOWER RD
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65536-9280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-718-1180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23604 RED OAK DR
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65536-5892
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-718-1180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LORI RANFELD
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 417-718-1180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------