=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366940504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW LEAF COUNSELING AND PSYCHOTHERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2018
-----------------------------------------------------
Last Update Date | 01/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1030 2N STREET SUITE B
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-387-4146
-----------------------------------------------------
Fax | 707-843-5608
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1030 2N STREET SUITE B
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-387-4146
-----------------------------------------------------
Fax | 707-843-5608
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | MS. GAYLE JANET WHITLOCK
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 707-387-8414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 84009
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------