=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407298318
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANCY BAPTIST L.M.H.C. N.C.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2013
-----------------------------------------------------
Last Update Date | 07/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4916 26TH ST W #100
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34207-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-556-1377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6459 EGRET LN #420
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34210-4214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-556-1377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH 9354
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------