=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841711033
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLIVE BRANCH COUNSELING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2017
-----------------------------------------------------
Last Update Date | 06/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9033 BASELINE RD STE A
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-1214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-989-9030
-----------------------------------------------------
Fax | 909-989-9030
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9033 BASELINE RD STE A
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-1214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-989-9030
-----------------------------------------------------
Fax | 909-466-4594
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL BILLER
-----------------------------------------------------
Name | NORMA COMBS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-989-9030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------