=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154988285
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAURELWOOD EQUINE ASSISTED DISCOVERIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2019
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1410 COUNTY ROAD 490
-----------------------------------------------------
City | HANCEVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35077-8127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-277-1551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 431
-----------------------------------------------------
City | CULLMAN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35056-0431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | ASHLEY LEE
-----------------------------------------------------
Credential | MS, LPC
-----------------------------------------------------
Telephone | 256-476-0794
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------