=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912640228
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERAPY NEAR ME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2022
-----------------------------------------------------
Last Update Date | 10/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 MAIN ST
-----------------------------------------------------
City | CARBONDALE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81623-1936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-710-9074
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1233
-----------------------------------------------------
City | CARBONDALE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81623-1233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-710-9074
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | ANGELA FULLERTON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 970-710-9074
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------