=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982241436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRANQUIL SPACES COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2019
-----------------------------------------------------
Last Update Date | 12/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 E WILSON AVE
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68701-2969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-340-9092
-----------------------------------------------------
Fax | 888-920-1942
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 404 N 3RD ST
-----------------------------------------------------
City | PLAINVIEW
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68769-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-340-9092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TRACI S. GAYLOR
-----------------------------------------------------
Credential | LIMHP, LPC
-----------------------------------------------------
Telephone | 402-340-9092
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------