=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215468467
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HENDRICK COUNSELING SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2017
-----------------------------------------------------
Last Update Date | 03/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 PARK AVE
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37087-3664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-449-9611
-----------------------------------------------------
Fax | 615-453-7051
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 PARK AVE
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-449-9611
-----------------------------------------------------
Fax | 615-453-7051
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. KIMBERLEY HENDRICK
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 615-449-9611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TP0016X
-----------------------------------------------------
Taxonomy Name | Prescribing (Medical) Psychologist
-----------------------------------------------------
License Number | APN0000012314
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------