=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942767124
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUR LEAF COUNSELING AND CONSULTING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2019
-----------------------------------------------------
Last Update Date | 02/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 S WATER ST
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89015-7524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-376-0732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 419 SHAMROCK DR
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89002-8332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-376-0732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | TAYLA DIANE HADLEY
-----------------------------------------------------
Credential | M.ED CPC CADC
-----------------------------------------------------
Telephone | 702-376-0732
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------