=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750710752
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRAINING GROUND
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2013
-----------------------------------------------------
Last Update Date | 11/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 32ND ST
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23607-3309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-301-7129
-----------------------------------------------------
Fax | 757-301-7211
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 32ND ST
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23607-3309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-301-7129
-----------------------------------------------------
Fax | 757-301-7211
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RICHARD MASON JR.
-----------------------------------------------------
Credential | PHD, LPC, ACS
-----------------------------------------------------
Telephone | 757-301-7129
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0701003229
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------