=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235533746
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DALE KIRKHAM LPC MHSP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2014
-----------------------------------------------------
Last Update Date | 10/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2021 21ST AVE S ROOM 322
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37212-4342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-420-0201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 199 HARPETH VIEW TRL
-----------------------------------------------------
City | KINGSTON SPRINGS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37082-9047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-420-0201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2988
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------