=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780010926
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE ABUNDANT COUNSELING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2013
-----------------------------------------------------
Last Update Date | 09/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4127 HOBBS ST
-----------------------------------------------------
City | BACLIFF
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77518-2350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-413-7093
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4127 HOBBS ST
-----------------------------------------------------
City | BACLIFF
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77518-2350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-413-7093
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESEDENT
-----------------------------------------------------
Name | MR. WILLIAM ALLEN MILLER
-----------------------------------------------------
Credential | C.T.C.
-----------------------------------------------------
Telephone | 281-413-7093
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP1600X
-----------------------------------------------------
Taxonomy Name | Pastoral Counselor
-----------------------------------------------------
License Number | 15541
-----------------------------------------------------
License Number State |
-----------------------------------------------------