=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386168771
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAIN STREET COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2017
-----------------------------------------------------
Last Update Date | 07/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1069- MAIN STREET STE 216
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-766-9152
-----------------------------------------------------
Fax | 772-766-9152
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1036-MAIN STREET STE 216
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-766-9152
-----------------------------------------------------
Fax | 772-766-9152
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JAMES RANAHAN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 772-766-9152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW9080
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------