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General NPI Number Information
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NPI Number | 1568960128
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Entity Type | Organization
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Legal Business Name | MY ALL ENTERPRISES, INC.
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Dates
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Enumeration Date | 01/30/2018
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Last Update Date | 01/30/2018
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Provider Practice Location Address
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Address Line | 131 OLD BROOK RD STE C
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City | VINTON
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State | VA
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Zip | 24179-4301
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Country | US
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Telephone | 540-797-9620
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Fax |
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Provider Business Mailing Address
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Address Line | 3353 GLADE CREEK BLVD NE APT 11
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City | ROANOKE
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State | VA
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Zip | 24012-8659
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Country | US
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Telephone | 540-797-9620
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | TRACIE MICHELLE ETTER
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Credential | LCSW
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Telephone | 540-797-9620
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 0904009900
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License Number State | VA
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