=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962032201
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACON OF HOPE COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2020
-----------------------------------------------------
Last Update Date | 01/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 424 OVERLOOK RD
-----------------------------------------------------
City | LAKE OZARK
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65049-7139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-286-7262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 424 OVERLOOK RD
-----------------------------------------------------
City | LAKE OZARK
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65049-7139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-286-7262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | MRS. JILL BERNIVA WADE-SCOTT
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 573-286-7262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------