=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275986937
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REFLECTIONS PROFESSIONAL COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2016
-----------------------------------------------------
Last Update Date | 07/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5103 EASTMAN AVE SUITE 217
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48640-6785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-423-8945
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2020 N MONARCH CIR
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48642-6853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANDREA STICKEL
-----------------------------------------------------
Credential | MA, LLPC
-----------------------------------------------------
Telephone | 317-417-5235
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 6401015514
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------