=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154003820
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WISE COUNSEL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2023
-----------------------------------------------------
Last Update Date | 08/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2055 CRAIGSHIRE RD STE 350D
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63146-4028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-737-9634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1405 OLROYD DR
-----------------------------------------------------
City | SWANSEA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62226-8565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-FOUNDER
-----------------------------------------------------
Name | CARMEL BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-737-9634
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------