=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740927003
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIND HARBOR COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2022
-----------------------------------------------------
Last Update Date | 09/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 DEVONSHIRE DR STE D-2B
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61820-7337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-854-9661
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 DEVONSHIRE DR STE D-2B
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61820-7337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-854-9661
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROSE ST CLAIR
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 312-854-9661
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------