=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124377403
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WORRY FREE COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2012
-----------------------------------------------------
Last Update Date | 12/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2520 ELIZABETH LAKE RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48328-3312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-249-5453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3016 HAVENWOOD DR
-----------------------------------------------------
City | WHITE LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48383-3903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-249-5453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | MRS. JEANETTE ELAINE OWENS
-----------------------------------------------------
Credential | MA, LLPC
-----------------------------------------------------
Telephone | 248-249-5453
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | L264721
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------