=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619287190
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN LIGHT COUNSELING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2010
-----------------------------------------------------
Last Update Date | 01/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 N ELM ST STE 801
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27401-2083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-274-1237
-----------------------------------------------------
Fax | 336-274-1236
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 N ELM ST STE 801
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27401-2083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-274-1237
-----------------------------------------------------
Fax | 336-274-1236
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | MR. JASON W STRACK
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 336-274-1237
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------