=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952703647
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SELF-EMPOWERMENT-NH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2014
-----------------------------------------------------
Last Update Date | 09/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 85 WARREN ST
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03301-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-470-6937
-----------------------------------------------------
Fax | 603-856-8240
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 85 WARREN ST
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03301-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-470-6937
-----------------------------------------------------
Fax | 603-856-8240
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUBSTANCE ABUSE COUNSELOR
-----------------------------------------------------
Name | MRS. LORI LEE MAGOON
-----------------------------------------------------
Credential | MLADC
-----------------------------------------------------
Telephone | 603-470-6937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 0683
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------