MEDICARE: ELLICE PARK LLC DBA COUNSELING CARE CIRCLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	101YP1600X	Pastoral Counselor
4	101YP2500X	Professional Counselor
5	101YS0200X	School Counselor
6	102L00000X	Psychoanalyst
7	103T00000X	Psychologist
8	104100000X	Social Worker
9	106S00000X	Behavior Technician
10	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
11	261QM0850X	Adult Mental Health Clinic/Center
12	261QM0855X	Adolescent and Children Mental Health Clinic/Center
13	282J00000X	Religious Nonmedical Health Care Institution
14	374K00000X	Religious Nonmedical Practitioner
15	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1457029373
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLICE PARK LLC DBA COUNSELING CARE CIRCLE

Provider Business Mailing Address
First Line	:	PO BOX 2465
Second Line	:
City	:	HARRISBURG
State	:	PA
Zip	:	17105-2465
Country	:	US
Telephone Number	:	614-568-3233
Fax Number	:

Provider Business Practice Location Address
First Line	:	180 E BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43215-3707
Country	:	US
Telephone Number	:	614-568-3233
Fax Number	:

Authorized Official
Title or Position	:	AGENT
Name	:	VIRTUAL MUSTARD SEED
Credential	:
Telephone Number	:	614-568-3233

Provider Enumeration Date	:	09/03/2021
Last Update Date	:	02/03/2025

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