=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063881795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALANCED LIFE CONCEPTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2015
-----------------------------------------------------
Last Update Date | 09/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4306 ATCHISON AVE
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72762-6643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-361-0102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3102 SE J ST
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-3796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-361-0102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | MRS. TEMPLE CARSON
-----------------------------------------------------
Credential | MS
-----------------------------------------------------
Telephone | 479-361-0102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | P1207076
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------