=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942841317
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPSURGE COUNSELING AND CONSULTING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2019
-----------------------------------------------------
Last Update Date | 11/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20600 EUREKA RD STE 817
-----------------------------------------------------
City | TAYLOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48180-5377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-546-1026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20600 EUREKA RD STE 817
-----------------------------------------------------
City | TAYLOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48180-5377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-546-1026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. VALORIE EVANS
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 313-775-7577
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------