=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306473145
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIE WEATHERHEAD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2020
-----------------------------------------------------
Last Update Date | 03/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1624 ESTATES DR
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48206-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-626-3873
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1624 ESTATES DR
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48206-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-626-3873
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YS0200X
-----------------------------------------------------
Taxonomy Name | School Counselor
-----------------------------------------------------
License Number | IF0000000336996
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401018231
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------