=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376305789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPAL & WILLOW COUNSELING & WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2024
-----------------------------------------------------
Last Update Date | 01/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3248 JONAGOLD DR
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17110-9119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-350-0123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3248 JONAGOLD DR
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17110-9119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-350-0123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | DENISE LYNN VERCHIMAK
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 717-350-0123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------