=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720299688
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MISSING PIECES.ORG
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 01/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3798 ASBURY LANE
-----------------------------------------------------
City | MURFREESBORO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-330-4770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1784 W. NORTHFIELD BLVD. #123
-----------------------------------------------------
City | MURFREESBORO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-330-4770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. TRUDY M JOHNSON
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 719-330-4770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 755
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 1182
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------