=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073029385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARREFOUR COUNSELING & PLAY THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2017
-----------------------------------------------------
Last Update Date | 05/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 W GRAYSON ST
-----------------------------------------------------
City | GALAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24333-2811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-383-0400
-----------------------------------------------------
Fax | 855-877-4676
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 768
-----------------------------------------------------
City | GALAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24333-0768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-266-7513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR/PRESIDENT
-----------------------------------------------------
Name | MR. CHRISTOPHER LEE BELCHER
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 276-266-7513
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------