=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205282449
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REAL LIFE COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2016
-----------------------------------------------------
Last Update Date | 05/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21-25 E ELLENDALE STREET SUITE B, 2ND FLOOR
-----------------------------------------------------
City | BEL AIR
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21014-2924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-655-7164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 837
-----------------------------------------------------
City | FOREST HILL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21050-0837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-655-7164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SUPERVISOR
-----------------------------------------------------
Name | MS. LINDA LOUISE SMITH
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 443-655-7164
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LC1174
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------