=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841005543
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARBOR SITE COUNSELING AND CONSULTING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2025
-----------------------------------------------------
Last Update Date | 02/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 MAIN AVE
-----------------------------------------------------
City | BROOKINGS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57006-1424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-689-5730
-----------------------------------------------------
Fax | 605-692-4972
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1733 TORREY PINES DR
-----------------------------------------------------
City | BROOKINGS
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57006-5418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-689-5730
-----------------------------------------------------
Fax | 605-692-4972
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RICHARD DANIEL KELLEY
-----------------------------------------------------
Credential | LPC-MH, QMHP
-----------------------------------------------------
Telephone | 605-692-4970
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------