=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629370515
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERATING LIVES: CHRISTIAN COUNSELING & PSYCHOL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2010
-----------------------------------------------------
Last Update Date | 11/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 N CENTER DR BLDG 11, SUITE 113
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23502-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-449-3671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 420 N CENTER DR BLDG 11, SUITE 113
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23502-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-449-3671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | MR. KEVIN J. COWARD
-----------------------------------------------------
Credential | M.A.
-----------------------------------------------------
Telephone | 757-449-3671
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 071003632
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------