=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093319725
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROYAL RIVER COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2020
-----------------------------------------------------
Last Update Date | 12/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 273 MAIN ST SUITE 4
-----------------------------------------------------
City | YARMOUTH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-558-2570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 273 MAIN ST SUITE 4
-----------------------------------------------------
City | YARMOUTH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-558-2570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NICK SMITH
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 207-239-5027
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------