=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255876934
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVEALED COUNSELING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2017
-----------------------------------------------------
Last Update Date | 01/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4610 PORTOFINO WAY 207
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33409-8154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-557-2741
-----------------------------------------------------
Fax | 561-469-2447
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 223586
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33422-3586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-557-2741
-----------------------------------------------------
Fax | 561-469-2447
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/VISIONARY
-----------------------------------------------------
Name | TD MCNUTT
-----------------------------------------------------
Credential | DR.
-----------------------------------------------------
Telephone | 561-557-2741
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------