=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396527594
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT TRAIL THERAPEUTIC SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2023
-----------------------------------------------------
Last Update Date | 10/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 HIGHLAND CIR
-----------------------------------------------------
City | BLUE RIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30513-3602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-383-9989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 EMERALD LN
-----------------------------------------------------
City | MINERAL BLUFF
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30559-2927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | LINDSEY RADABAUGH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 770-289-5528
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------