=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467952374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLAS CHILD COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2018
-----------------------------------------------------
Last Update Date | 02/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 275 PINEHURST AVE STE A
-----------------------------------------------------
City | SOUTHERN PINES
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28387-7138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-224-2307
-----------------------------------------------------
Fax | 910-684-8206
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 275 PINEHURST AVE STE A
-----------------------------------------------------
City | SOUTHERN PINES
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28387-7138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-224-2307
-----------------------------------------------------
Fax | 910-684-8206
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHILD THERAPIST
-----------------------------------------------------
Name | MR. JOHN LAWSON
-----------------------------------------------------
Credential | LCSW, MSW, RPT
-----------------------------------------------------
Telephone | 910-224-2307
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | P008888
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------