=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467973859
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THRIVING FAMILIES COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2017
-----------------------------------------------------
Last Update Date | 07/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1719 GRANDIN RD SW
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24015-2815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-915-6472
-----------------------------------------------------
Fax | 540-915-6472
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5052 PLEASANT HILL DR
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24018-3456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-915-6472
-----------------------------------------------------
Fax | 855-515-5360
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SUSAN L OWEN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 540-915-6472
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 094005310
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------