=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871006817
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE COUNTRY COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2017
-----------------------------------------------------
Last Update Date | 11/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 516 W ATLANTIC ST
-----------------------------------------------------
City | SOUTH HILL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23970-1906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-774-7559
-----------------------------------------------------
Fax | 434-447-3579
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 516 W ATLANTIC ST
-----------------------------------------------------
City | SOUTH HILL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23970-1906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-774-7559
-----------------------------------------------------
Fax | 434-447-3579
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LIC CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | TESSIE S SMITH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 434-774-7559
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904006071
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------