=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821406000
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPIRES BEHAVIORAL HEALTH CARE CENTER, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2014
-----------------------------------------------------
Last Update Date | 07/31/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4428 LAFAYETTE STREET
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32447-5728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-482-4177
-----------------------------------------------------
Fax | 850-482-4178
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5728 4428 LAFAYETTE STREET
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32447-5728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-482-4177
-----------------------------------------------------
Fax | 850-482-4178
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DR. WILLIE EARL SPIRES
-----------------------------------------------------
Credential | PH.D., L.M.H.C.
-----------------------------------------------------
Telephone | 850-482-4177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH0026
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------