=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831499086
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COBBLESTONE COUNSELING CENTER, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2010
-----------------------------------------------------
Last Update Date | 10/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19824 W CATAWBA AVE SUITE G-201
-----------------------------------------------------
City | CORNELIUS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28031-4046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-433-6644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2684
-----------------------------------------------------
City | CORNELIUS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28031-2684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-433-6644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. CANDACE M FARMER
-----------------------------------------------------
Credential | MSW, LCSW
-----------------------------------------------------
Telephone | 704-433-6644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C006688
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------