=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063952844
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PELORUS COUNSELING AND CONSULTING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2017
-----------------------------------------------------
Last Update Date | 02/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3306 BOURBON ST
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22408-7311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-371-3412
-----------------------------------------------------
Fax | 540-479-8237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3306 BOURBON ST
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22408-7311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-371-3412
-----------------------------------------------------
Fax | 540-479-8237
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | TIFFANY HARVEY
-----------------------------------------------------
Credential | LPC, NCC, CCMHC
-----------------------------------------------------
Telephone | 540-371-3412
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0701005985
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------