=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245588409
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHANGING TREE WELLNESS CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2012
-----------------------------------------------------
Last Update Date | 02/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 203 SE 2ND AVE
-----------------------------------------------------
City | OKEECHOBEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34974-4305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-261-8900
-----------------------------------------------------
Fax | 863-279-1156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 203 SE 2ND AVE
-----------------------------------------------------
City | OKEECHOBEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34974-4305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-261-8900
-----------------------------------------------------
Fax | 863-279-1156
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | DR. ELLISA SCOTT
-----------------------------------------------------
Credential | PHD, LMHC,CAP
-----------------------------------------------------
Telephone | 863-261-8900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | MH10761
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH10761
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 102L00000X
-----------------------------------------------------
Taxonomy Name | Psychoanalyst
-----------------------------------------------------
License Number | MH10761
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | MH10761
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------