=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548497696
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEHAVIORAL COUNSELING AND INTERVENTION MANAGEMENT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2009
-----------------------------------------------------
Last Update Date | 06/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 511 TELFAIR ST
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31021-5144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-274-9003
-----------------------------------------------------
Fax | 478-275-1916
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 787 OLD MACON RD
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31021-0941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-274-9003
-----------------------------------------------------
Fax | 478-275-1916
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | MS. MARTHA C MINCEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 478-275-7854
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | LPC003234
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------