=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568764827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELLIS COUNTY CHILDREN'S ADVOCACY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2010
-----------------------------------------------------
Last Update Date | 08/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 425 E ROSS ST
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75165-2636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-937-1870
-----------------------------------------------------
Fax | 972-937-1891
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 E ROSS ST
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75165-2636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-937-1870
-----------------------------------------------------
Fax | 972-937-1891
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MS. JAMIE GAIL ENGLISH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 972-937-1870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 64649
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------