=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659109833
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW WHITTEMORE DANIEL LCMHCA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2024
-----------------------------------------------------
Last Update Date | 07/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21024 CATAWBA AVE
-----------------------------------------------------
City | CORNELIUS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28031-8585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-355-8084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235 S CHURCH ST
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27101-5305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-355-8084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | A20312
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------