=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871058917
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESCOTT COMMUNITY COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2019
-----------------------------------------------------
Last Update Date | 02/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 SERI DR
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86303-7214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-277-4832
-----------------------------------------------------
Fax | 928-227-1140
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 711 SERI DR
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86303-7214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-277-4832
-----------------------------------------------------
Fax | 928-227-1140
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | LAURA HENRY OLIVER
-----------------------------------------------------
Credential | MS, LPC, NCC
-----------------------------------------------------
Telephone | 928-277-4832
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------