=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427712298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARROTHERS WELLNESS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2021
-----------------------------------------------------
Last Update Date | 10/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 N BRIDGE ST
-----------------------------------------------------
City | DEWITT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48820-8900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-776-5665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23565 WESLEY DR
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48335-3348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-776-5665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHRISTINE CARROTHERS
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 734-776-5665
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------