=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447866751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROPEL COUNSELING GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2020
-----------------------------------------------------
Last Update Date | 09/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 COURTHOUSE LN
-----------------------------------------------------
City | CLINTWOOD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24228-7911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-393-2367
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3855 DC CANEY RIDGE RD
-----------------------------------------------------
City | CLINTWOOD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24228-7861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KIMBERLY CARROLL
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 276-393-2367
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------