=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487368130
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRANSCEND OUTDOOR THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2023
-----------------------------------------------------
Last Update Date | 01/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21299 LOIS LN
-----------------------------------------------------
City | HOWARD CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49329-8737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-429-2979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 338
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49412-0338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-429-2979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-FOUNDER, THERAPIST
-----------------------------------------------------
Name | JACOB FIELDS
-----------------------------------------------------
Credential | M. ED, LLPC
-----------------------------------------------------
Telephone | 231-429-2979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------