=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114653946
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSANNE NEAL DBA CLEARWATER COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2022
-----------------------------------------------------
Last Update Date | 07/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1206 HARRISON AVE
-----------------------------------------------------
City | LEADVILLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80461-3327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-293-0750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 759
-----------------------------------------------------
City | LEADVILLE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80461-0759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-293-0750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER- LICENCES PROFESSIONAL OCUNSE
-----------------------------------------------------
Name | SUSANNE BRIDGETTE NEAL
-----------------------------------------------------
Credential | LPC LAC
-----------------------------------------------------
Telephone | 719-293-0750
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------