=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639246010
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAKIN CHOICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2006
-----------------------------------------------------
Last Update Date | 04/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1076 STAMPER RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-4191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-483-2002
-----------------------------------------------------
Fax | 910-483-4004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1076 STAMPER RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-4191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-483-2002
-----------------------------------------------------
Fax | 910-483-4004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO OWNER MA LPC
-----------------------------------------------------
Name | MS. RACHELLE BROOKS BLUE
-----------------------------------------------------
Credential | MA LPCS NCC CCSOTS
-----------------------------------------------------
Telephone | 910-257-4339
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------