=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316338783
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LTC COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2015
-----------------------------------------------------
Last Update Date | 02/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 797 WASHINGTON ST SUITE 4
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02460-1633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-877-0805
-----------------------------------------------------
Fax | 617-500-4120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 797 WASHINGTON ST SUITE 4
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02460-1633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-877-0805
-----------------------------------------------------
Fax | 617-500-4120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | SIREL TANER-CABALLERO
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 978-549-6401
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 7982
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------