=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346718152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A QUIET PLACE COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2018
-----------------------------------------------------
Last Update Date | 11/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 W SOUTH ST
-----------------------------------------------------
City | HERNANDO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38632-2245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-214-9912
-----------------------------------------------------
Fax | 662-912-9082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 WREN ST
-----------------------------------------------------
City | HERNANDO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38632-4230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-500-8865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEBRA K SHELTON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 901-500-8865
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------