=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255895298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UJIMA COUNSELING, CONSULTING AND COACHING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2019
-----------------------------------------------------
Last Update Date | 01/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 LANTANA CT
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31520-2211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-471-3511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 LANTANA CT
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31520-2211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-471-3511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MICHAEL JEROME GILLIARD II
-----------------------------------------------------
Credential | LPC, NCC
-----------------------------------------------------
Telephone | 843-471-3511
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------