=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518369040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERITAGE COUNSELING AND CONSULTATION CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2014
-----------------------------------------------------
Last Update Date | 09/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 PEACEFUL DR
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42701-6465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-996-5877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 PEACEFUL DR
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42701-6465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-996-5877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | MS. GERALDINE HICKERSON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 270-996-5877
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 3394
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------