=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235688250
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERVE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2016
-----------------------------------------------------
Last Update Date | 10/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 N COMMERCE ST
-----------------------------------------------------
City | HINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31313-2720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-332-7503
-----------------------------------------------------
Fax | 855-898-5414
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 N MAIN ST
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30642-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-453-7400
-----------------------------------------------------
Fax | 855-898-5414
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/CEO
-----------------------------------------------------
Name | MRS. ANNETTE BENNECHE
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 912-332-7503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 006255
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------