=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154180461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIDDLEHEAD COUNSELING AND COACHING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2024
-----------------------------------------------------
Last Update Date | 03/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 PLAZA CIR STE 103
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50701-5139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-405-0009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 PLAZA CIR STE 103
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50701-5139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-405-0009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | JENNIFER RIKKERS
-----------------------------------------------------
Credential | LISW
-----------------------------------------------------
Telephone | 319-405-0009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------