=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972010627
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW FOUNDATIONS COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2018
-----------------------------------------------------
Last Update Date | 01/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 357 INKSTER RD
-----------------------------------------------------
City | INKSTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48141-1208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-805-4680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 357 INKSTER RD
-----------------------------------------------------
City | INKSTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48141-1208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-805-4680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DARNELL HURT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-805-4680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------