=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275019929
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNSELORMICHLIMITED LIABILITY COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2018
-----------------------------------------------------
Last Update Date | 07/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3762 MOFFETT RD STE A
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36618-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-447-3703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 CHIDESTER AVE
-----------------------------------------------------
City | MOBILE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36607-2119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 251-447-3703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LPC/CEO
-----------------------------------------------------
Name | MICHELLE EDWARDS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 251-447-3703
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 2306
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------