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General NPI Number Information
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NPI Number | 1215321963
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Entity Type | Organization
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Legal Business Name | COUNSELING INC., DBA ALLIANCE COUNSELING
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Dates
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Enumeration Date | 03/19/2015
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Last Update Date | 03/19/2015
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Provider Practice Location Address
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Address Line | 17 RACETRACK RD NW
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-4616
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Country | US
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Telephone | 850-226-6828
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Fax |
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Provider Business Mailing Address
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Address Line | 17 RACETRACK RD NW
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-4616
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Country | US
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Telephone | 850-226-6828
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH COUNSELOR
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Name | DEANNA HICKENBOTHAM
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Credential | LMHC
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Telephone | 850-226-7226
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH11935
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License Number State | FL
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