=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407266604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORNERSTONE WELLNESS GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2014
-----------------------------------------------------
Last Update Date | 04/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 E. CROCKETT ST.
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77327-9998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-593-1888
-----------------------------------------------------
Fax | 281-593-1890
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 405 E. CROCKETT ST.
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77327-9998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-593-1888
-----------------------------------------------------
Fax | 281-593-1890
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFFESIONAL COUNSELOR
-----------------------------------------------------
Name | LOIS MARIE LIDDLE
-----------------------------------------------------
Credential | LPC-S
-----------------------------------------------------
Telephone | 281-593-1888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 12361
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------