=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497027213
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARRY M. KIRKLAND, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2012
-----------------------------------------------------
Last Update Date | 02/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4435 MARION ST
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32448-4630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-482-0019
-----------------------------------------------------
Fax | 850-482-0015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 285 W LAKEVIEW DR
-----------------------------------------------------
City | WEWAHITCHKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32465-7525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-323-1002
-----------------------------------------------------
Fax | 850-482-0015
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MR. LARRY M. KIRKLAND
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 850-323-1002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | MH8715
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------