MEDICARE: INTROSPECTION & REFLECTION

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health	009203	GA

General Provider Information

NPI Number	:	1467990119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTROSPECTION & REFLECTION

Provider Business Mailing Address
First Line	:	184 HAMILTON GROVE DRIVE
Second Line	:
City	:	POOLER
State	:	GA
Zip	:	31322
Country	:	US
Telephone Number	:	912-346-5344
Fax Number	:

Provider Business Practice Location Address
First Line	:	184 HAMILTON GROVE DR
Second Line	:
City	:	POOLER
State	:	GA
Zip	:	31322-9644
Country	:	US
Telephone Number	:	912-346-5344
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAYSHA PHIMPHONE
Credential	:	LPC
Telephone Number	:	912-346-5344

Provider Enumeration Date	:	02/02/2017
Last Update Date	:	02/02/2017

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Directions to “INTROSPECTION & REFLECTION ” Practice Location

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