=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124341854
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADELINE MCTAVOUS PH.D., LPC, LMHC,CCS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2010
-----------------------------------------------------
Last Update Date | 09/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 CHARLIE SMITH SR HWY STE 6
-----------------------------------------------------
City | SAINT MARYS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-576-0187
-----------------------------------------------------
Fax | 912-576-9690
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 CHARLIE SMITH SR HWY STE 6
-----------------------------------------------------
City | SAINT MARYS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31558-3032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-576-0187
-----------------------------------------------------
Fax | 912-576-9690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LC3272
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------