MEDICARE: TRANSITIONAL LIFE COUNSELING

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	103TC0700X	Clinical Psychologist	6323	OH
2	101YP2500X	Professional Counselor	E0600045	OH

General Provider Information

NPI Number	:	1790222370
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRANSITIONAL LIFE COUNSELING

Provider Business Mailing Address
First Line	:	1525 XENIA AVE
Second Line	:
City	:	YELLOW SPRINGS
State	:	OH
Zip	:	45387-1123
Country	:	US
Telephone Number	:	937-769-5019
Fax Number	:	937-769-5019

Provider Business Practice Location Address
First Line	:	1525 XENIA AVE
Second Line	:
City	:	YELLOW SPRINGS
State	:	OH
Zip	:	45387-1123
Country	:	US
Telephone Number	:	937-769-5019
Fax Number	:	937-769-5019

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST/OWNER
Name	:	DR. ROSE MARY SHAW
Credential	:	PSYD
Telephone Number	:	937-769-5019

Provider Enumeration Date	:	01/20/2017
Last Update Date	:	12/04/2017

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