=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871110742
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GROUNDED INTEGRATIVE COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2020
-----------------------------------------------------
Last Update Date | 09/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1616 EUCLID AVE
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24201-3734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-378-9407
-----------------------------------------------------
Fax | 276-889-6823
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 TIMBER OAK DR
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24201-3065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-696-1899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MELANIE M WILLIAMS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 276-696-1899
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------