=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124492954
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DONNATHERESE MCCARRELL LLPC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2015
-----------------------------------------------------
Last Update Date | 11/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3031 KELLEN DR
-----------------------------------------------------
City | TECUMSEH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49286-8650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-414-5123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 904 W CHICAGO BLVD STE. B
-----------------------------------------------------
City | TECUMSEH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49286-1298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-414-5123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. DONNA THERESE MCCARRELL
-----------------------------------------------------
Credential | M.A., LPC
-----------------------------------------------------
Telephone | 517-414-5123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401008406
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------