=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649722794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | C & A COUNSELING LLLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2016
-----------------------------------------------------
Last Update Date | 10/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2323 MAIN ST STE B-1
-----------------------------------------------------
City | TUCKER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30084-8522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-643-3593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2323 MAIN ST STE B-1
-----------------------------------------------------
City | TUCKER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30084-8522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-643-3593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | MRS. ASHLEY SKIDMORE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 404-643-3593
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | CSW004895
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------