=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346904331
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHILOH'S COUNSELING AND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2021
-----------------------------------------------------
Last Update Date | 10/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3634 CENTRAL AVE STE A
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71913-6472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-547-3763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3634 CENTRAL AVE STE A
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71913-6472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-547-3763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | JASON WALLER
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 501-547-3763
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------