=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225049760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL COUNSELING CENTER,P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 02/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 SUPERIOR ST
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060-3838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-984-4202
-----------------------------------------------------
Fax | 810-984-8896
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 SUPERIOR ST
-----------------------------------------------------
City | PORT HURON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-984-4202
-----------------------------------------------------
Fax | 810-984-8896
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | TERRI LYNN MOSS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 810-294-4880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 740040
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------