=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295515310
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROUSEL PROJECT, COMMUNITY CARE COUNSELING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2023
-----------------------------------------------------
Last Update Date | 10/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6994 SUNNYSIDE RD S. 1043 TWINWOOD CT NW
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-991-3588
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6994 SUNNYSIDE RD S.
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-991-3588
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. KAYLENE SCHOLL HENDERSON
-----------------------------------------------------
Credential | MCOUNS.,ED.D, CANDID
-----------------------------------------------------
Telephone | 503-991-3588
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------