=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780741132
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARKPLACE COUNSELING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 W MAIN ST SUITE 3C
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97501-2744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-245-9610
-----------------------------------------------------
Fax | 541-245-9629
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 W MAIN ST SUITE 3C
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97501-2744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-245-9610
-----------------------------------------------------
Fax | 541-245-9629
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | MARCIA OVERSTREET
-----------------------------------------------------
Credential | MS, LPC
-----------------------------------------------------
Telephone | 541-245-9610
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | C1733
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------