=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609605385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURPLE LOTUS SOLUTIONS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2024
-----------------------------------------------------
Last Update Date | 07/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2683 US HIGHWAY 34
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60543-8577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-337-0827
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2683 US HIGHWAY 34
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60543-8577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-337-0827
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CLINICAL THERAPIST
-----------------------------------------------------
Name | MINDY M. BURKHAMER
-----------------------------------------------------
Credential | LCSW, CADC, CODP-II
-----------------------------------------------------
Telephone | 630-337-0827
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------