=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477738847
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHY PEACOCK FRALEY LPC, MHSP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2008
-----------------------------------------------------
Last Update Date | 01/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 859 MCCALLIE AVE
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37403-2621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-322-3178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 859 MCCALLIE AVE
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37403-2621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-322-3178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0000000829
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------