=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376814004
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE LITTLE VILLAGE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2012
-----------------------------------------------------
Last Update Date | 05/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 241 E MAIN ST
-----------------------------------------------------
City | GRASS VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95945-6507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-802-5207
-----------------------------------------------------
Fax | 530-802-5207
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 241 E MAIN ST
-----------------------------------------------------
City | GRASS VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95945-6507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-802-5207
-----------------------------------------------------
Fax | 530-802-5207
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PAULETTE M LUCIER
-----------------------------------------------------
Credential | PH.D, MFT, LCSW
-----------------------------------------------------
Telephone | 530-802-5207
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT38010
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------