=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508236332
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYOU COUNSELING SERVICES, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2015
-----------------------------------------------------
Last Update Date | 10/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 GOVERNMENT AVE SUITE A
-----------------------------------------------------
City | NICEVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32578-1868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-678-1746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 GOVERNMENT AVE SUITE A
-----------------------------------------------------
City | NICEVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32578-1868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-678-1746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. JANICE MARIE COLLIER
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 850-678-1846
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 3495
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------