=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952064180
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORA COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2021
-----------------------------------------------------
Last Update Date | 10/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1406 N MAIN ST STE 210
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-1746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-613-9514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5254 N CORTONA WAY
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-3121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-613-9514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIAL SPECIALIST
-----------------------------------------------------
Name | JEANETTE JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-800-2332
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------