=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902520778
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHOOSE CHANGE CONVINCE COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2022
-----------------------------------------------------
Last Update Date | 09/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1103 EVANS AVE
-----------------------------------------------------
City | POTOSI
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63664-1315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-631-0640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1103 EVANS AVE
-----------------------------------------------------
City | POTOSI
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63664-1315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-631-0640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | CARRIE M. MERCER
-----------------------------------------------------
Credential | MSW, LCSW
-----------------------------------------------------
Telephone | 573-631-0640
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------