=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053884163
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESTORATION COUNSELING & CONSULTATION, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2019
-----------------------------------------------------
Last Update Date | 01/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7926 W 21ST ST N
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67205-1742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-272-5502
-----------------------------------------------------
Fax | 316-462-5640
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7926 W 21ST ST N
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67205-1742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-272-5502
-----------------------------------------------------
Fax | 316-462-5640
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MATTHEW GALLAGHER
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 316-272-5502
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------