=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518497924
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OUR PLACE TO SOAR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2017
-----------------------------------------------------
Last Update Date | 06/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2603 KEISER BLVD STE 201
-----------------------------------------------------
City | WYOMISSING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19610-3341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-207-5279
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 483 OLEY RD
-----------------------------------------------------
City | FLEETWOOD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19522-8861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR/OWNER
-----------------------------------------------------
Name | KAREN MADEIRA
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 610-207-5279
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number | PC005422
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------