=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225635196
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGEL'S POND COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2020
-----------------------------------------------------
Last Update Date | 10/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 208 SEARCY ST
-----------------------------------------------------
City | ENTERPRISE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36330-2739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-477-4531
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 HERON COVE DR APT D214
-----------------------------------------------------
City | ENTERPRISE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-477-4531
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | EMILY THARPE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 334-791-2474
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------