=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457756686
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESTORE COUNSELING & CARE MANAGEMENT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2014
-----------------------------------------------------
Last Update Date | 10/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 CHURCH ST STE 105-107
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-259-8787
-----------------------------------------------------
Fax | 770-995-1959
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1697 WADE AVE NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30317-2053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-259-8787
-----------------------------------------------------
Fax | 770-995-1959
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EMILY A FITZPATRICK
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 404-259-8787
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC007985
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------