=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376008433
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREVAIL COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2019
-----------------------------------------------------
Last Update Date | 02/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 MID CONTINENT PLZ STE 404
-----------------------------------------------------
City | WEST MEMPHIS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72301-1700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-294-9522
-----------------------------------------------------
Fax | 855-765-7701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 706 CARTER DR
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72364-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-295-9422
-----------------------------------------------------
Fax | 855-765-7701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INCORPORATOR
-----------------------------------------------------
Name | RACHEL NELSON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 901-295-9422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------