=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811279466
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANCY RAE MS, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2011
-----------------------------------------------------
Last Update Date | 09/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 N WELLINGTON ST
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75670-3335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-938-4476
-----------------------------------------------------
Fax | 903-938-4125
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8317
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75671-8317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-938-4476
-----------------------------------------------------
Fax | 903-938-4125
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 05250
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------