=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568903706
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVER CITIES COUNSELING & CONSULTING INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2017
-----------------------------------------------------
Last Update Date | 03/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 643 BLACKBURN AVE
-----------------------------------------------------
City | CORNING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96021-2216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-824-4408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 492551
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96049-2551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-223-5779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MARRIAGE & FAMILY THERAPIS
-----------------------------------------------------
Name | MR. GARY LEE FORTENBERRY
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 530-223-5779
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | LMFT 35841
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------