=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679055800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAFE TO SHORE COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2018
-----------------------------------------------------
Last Update Date | 09/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 134 N MAIN ST
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30458-5753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-687-1105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 211 THORNWOOD CT
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30458-0296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-687-1105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | JULIA A JEROME
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 912-687-1105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 010358
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 010358
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------