=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770296816
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPITAL ART THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2023
-----------------------------------------------------
Last Update Date | 06/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 81 PEMBROKE RD
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03301-5754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-575-9159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 81 PEMBROKE RD
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03301-5754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-575-9159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SUSAN RIEDL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 603-575-9159
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 221700000X
-----------------------------------------------------
Taxonomy Name | Art Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------