=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912412404
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRYDEALIST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2017
-----------------------------------------------------
Last Update Date | 12/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4300 S I 10 SERVICE RD W
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70001-7405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-533-4996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4316 FERRAN DR
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70002-3130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-261-7706
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MOLLY HOLMES
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 504-261-7706
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 6458
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------