=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396004511
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORE COUNSELING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2012
-----------------------------------------------------
Last Update Date | 05/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 847 PARKCENTRE WAY STE 6&7
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83651-1792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-467-2673
-----------------------------------------------------
Fax | 208-467-4150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 847 PARKCENTRE WAY STE 6&7
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83651-1792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-467-2673
-----------------------------------------------------
Fax | 208-467-4150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MASTER SOCIAL WORKER
-----------------------------------------------------
Name | MR. TIMOTHY L KOBERLEIN
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 208-467-2673
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 30016
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------