=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457778110
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAITHWALK COMMUNITY DEVELOPMENT CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2014
-----------------------------------------------------
Last Update Date | 03/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 514 FOX ST.
-----------------------------------------------------
City | PARIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-327-5752
-----------------------------------------------------
Fax | 660-327-6233
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 119 514 FOX ST.
-----------------------------------------------------
City | PARIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-327-5752
-----------------------------------------------------
Fax | 660-327-6233
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FNP-
-----------------------------------------------------
Name | MISS BETTY WILSON
-----------------------------------------------------
Credential | NURSE PRACTIONER-LN#
-----------------------------------------------------
Telephone | 660-327-5752
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP1600X
-----------------------------------------------------
Taxonomy Name | Pastoral Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 2004028021
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------