=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295279099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY COUNSELING OF ELK GROVE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2016
-----------------------------------------------------
Last Update Date | 12/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8920 EMERALD PARK DR SUITE A
-----------------------------------------------------
City | ELK GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95624-2380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-512-5447
-----------------------------------------------------
Fax | 916-721-2447
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8920 EMERALD PARK DR SUITE A
-----------------------------------------------------
City | ELK GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95624-2380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-512-5447
-----------------------------------------------------
Fax | 916-721-2447
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | MRS. DAPHNE DAPHNE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 916-512-5447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 27778
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------