=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093204000
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITE DIAMOND COUNSELING CONSULTING COACHING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2018
-----------------------------------------------------
Last Update Date | 05/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 S CULVER ST
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30046-4806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-883-8609
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3932 PLYMOUTH ROCK DR
-----------------------------------------------------
City | LOGANVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30052-8712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-883-8609
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TERRO L WHITE
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 678-883-8609
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC008752
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------