=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164800363
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DALLAS NORMAN LPC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2015
-----------------------------------------------------
Last Update Date | 05/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 626 2ND ST SUITE 101A
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99701-3466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-455-5238
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 626 2ND ST SUITE 101A
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99701-3466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DALLAS P NORMAN
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 907-455-5238
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 1020553
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------