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General NPI Number Information
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NPI Number | 1104073592
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Entity Type | Organization
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Legal Business Name | THE CENTRE
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Dates
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Enumeration Date | 08/27/2008
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Last Update Date | 09/16/2008
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Provider Practice Location Address
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Address Line | 1290 MAIN ST STE E
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City | DAPHNE
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State | AL
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Zip | 36526-8624
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Country | US
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Telephone | 251-625-0118
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Fax | 251-625-0116
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Provider Business Mailing Address
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Address Line | 1290 MAIN ST STE E
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City | DAPHNE
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State | AL
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Zip | 36526-8624
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Country | US
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Telephone | 251-625-0118
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Fax | 251-625-0116
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. ROBERT EDWIN COLCLOUGH
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Credential | LPC
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Telephone | 251-625-0118
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LPC 111 AL
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License Number State | AL
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