=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508100819
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVATIVE COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2012
-----------------------------------------------------
Last Update Date | 11/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25251 SR 54,PMB 205
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-322-3850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7251 SR 54,PMB 205
-----------------------------------------------------
City | WESLEY CHAPEL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-322-3850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MR. JEFFREY BRIAN SMIALEK
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 813-838-3074
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | MH9288
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------