=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679000350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A CLEAN MIND LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2017
-----------------------------------------------------
Last Update Date | 05/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 E GOVERNMENT ST #C
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32502-8104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-501-1150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1610 E WRIGHT ST
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32501-4354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-501-1150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ASHLEY P PENNEWILL
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 850-501-1150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW11608
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------