=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336594860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR COUNSELING AND PSYCHOTHERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2016
-----------------------------------------------------
Last Update Date | 06/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6542B MINK HOLLOW RD
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20777-9760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-207-5025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6542B MINK HOLLOW RD
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20777-9760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-207-5025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO/OWNER
-----------------------------------------------------
Name | MICHAEL WILLIAM BISHOP
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-207-5025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------