=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174896492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSPIRED THERAPEUTIC SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2012
-----------------------------------------------------
Last Update Date | 02/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5830 MOUNT MORIAH RD SUITE 20
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38115-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-244-6182
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5830 MOUNT MORIAH RD SUITE 20
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38115-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-244-6182
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | VERONICA WADE
-----------------------------------------------------
Credential | LPC-MHSP
-----------------------------------------------------
Telephone | 901-647-8522
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC0000002465
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------