=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184012718
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CPPL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2015
-----------------------------------------------------
Last Update Date | 01/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3454 OAK ALLEY CT STE 406
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43606-1355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-742-2745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4111 SHAMLEY GREEN DR
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43623-3232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-787-2807
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL COUNSELOR
-----------------------------------------------------
Name | ESTIL CANTERBURY
-----------------------------------------------------
Credential | MA, LPCC
-----------------------------------------------------
Telephone | 419-742-2745
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | E. 0900306
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------