=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962004564
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEPHANT ROCK COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2020
-----------------------------------------------------
Last Update Date | 11/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 PROSPECT AVE STE T
-----------------------------------------------------
City | KIRKWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63122-6024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-200-4482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 PROSPECT AVE STE T
-----------------------------------------------------
City | KIRKWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63122-6024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-200-4482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | CHAD R RANDALL
-----------------------------------------------------
Credential | M.ED., LPC, CCDP-D
-----------------------------------------------------
Telephone | 314-200-4482
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------