=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659877934
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KUMMERLE PSYCHOTHERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2018
-----------------------------------------------------
Last Update Date | 04/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6000 NW 70TH AVENUE RD STE 225A
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34482-6735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-304-6955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6000 NW 70TH AVENUE RD STE 225A
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34482-6735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-304-6955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DIRK A KUMMERLE
-----------------------------------------------------
Credential | LMHC, LADC
-----------------------------------------------------
Telephone | 617-304-6955
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------