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General NPI Number Information
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NPI Number | 1487035267
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Entity Type | Organization
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Legal Business Name | RESTORATION COUNSELING
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Dates
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Enumeration Date | 06/17/2015
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Last Update Date | 06/17/2015
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Provider Practice Location Address
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Address Line | 415 W BROADWAY ST STE E
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City | FORTVILLE
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State | IN
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Zip | 46040-1462
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Country | US
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Telephone | 317-710-7772
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Fax |
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Provider Business Mailing Address
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Address Line | 415 W BROADWAY ST STE E
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City | FORTVILLE
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State | IN
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Zip | 46040-1462
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Country | US
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Telephone | 317-710-7772
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Fax |
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Authorized Official
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Title or Position | OWNER/THERAPIST
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Name | MRS. KELLY L SHORES
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Credential | MA
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Telephone | 317-710-7772
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 86000251A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 35001781A
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License Number State | IN
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