=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821542614
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ESPERANZA COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2016
-----------------------------------------------------
Last Update Date | 08/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 415 E WALNUT AVE SUITE 112
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30721-4406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-208-0630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 E WALNUT AVE SUITE 112
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30721-4406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-208-0630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | RACHEL LASKOWSKE
-----------------------------------------------------
Credential | L.P.C.
-----------------------------------------------------
Telephone | 423-208-0630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC008648
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------