=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386875078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPLETE CIRCLE COUNSELING & COACHING, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2009
-----------------------------------------------------
Last Update Date | 07/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 127 E AVENUE B STE B
-----------------------------------------------------
City | HUTCHINSON
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67501-7422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-259-7993
-----------------------------------------------------
Fax | 620-259-7994
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 127 E AVENUE B STE B
-----------------------------------------------------
City | HUTCHINSON
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67501-7422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-259-7993
-----------------------------------------------------
Fax | 620-259-7994
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LSCSW
-----------------------------------------------------
Name | REBECA SANDOVAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 620-694-4078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 3874
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------