=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396204012
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLAY THERAPY OF THE PINES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2019
-----------------------------------------------------
Last Update Date | 03/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 W PENNSYLVANIA AVE STE 54
-----------------------------------------------------
City | SOUTHERN PINES
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28387-5429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-390-0416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 W PENNSYLVANIA AVE STE 54
-----------------------------------------------------
City | SOUTHERN PINES
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28387-5429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-390-0416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MEGAN NUMBERS
-----------------------------------------------------
Credential | MA, LPC, RPT
-----------------------------------------------------
Telephone | 910-390-0416
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------