=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366528556
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMES WORTHAM COUNSELING SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2006
-----------------------------------------------------
Last Update Date | 02/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2580 MICHIGAN RD SUITE 3
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-265-1663
-----------------------------------------------------
Fax | 812-273-8964
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 40
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47250-0040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-265-1663
-----------------------------------------------------
Fax | 812-273-8964
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT DIRECTOR
-----------------------------------------------------
Name | MR. JAMES EDWARD WORTHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 812-265-1663
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | C474
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 34002443
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------