=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790027399
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADIANCE COUNSELING & CONSULTING P.L.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2013
-----------------------------------------------------
Last Update Date | 12/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7747 MITCHELL BLVD STE B
-----------------------------------------------------
City | TRINITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34655-4725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-941-6402
-----------------------------------------------------
Fax | 844-642-6304
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7747 MITCHELL BLVD STE B
-----------------------------------------------------
City | TRINITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34655-4725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | DR. MADELINE ALTABE
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 404-941-6402
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY4848
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------