=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538456942
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR COUNSELING, REHABILITATION, & PERSONAL EVALUATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2011
-----------------------------------------------------
Last Update Date | 07/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 331 ARCADO RD NW SUITE B
-----------------------------------------------------
City | LILBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30047-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-564-3230
-----------------------------------------------------
Fax | 770-564-3792
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 331 ARCADO RD NW SUITE B
-----------------------------------------------------
City | LILBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30047-2814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-564-3230
-----------------------------------------------------
Fax | 770-564-3792
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, HEAD CLINICIAN
-----------------------------------------------------
Name | ROBIN DOCK
-----------------------------------------------------
Credential | PH.D., L.P.C.
-----------------------------------------------------
Telephone | 770-564-3230
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC003265
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------