MEDICARE: SHADOW HORSE COUNSELING, LLC

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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1891381620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHADOW HORSE COUNSELING, LLC

Provider Business Mailing Address
First Line	:	PO BOX 84
Second Line	:
City	:	PINE MOUNTAIN VALLEY
State	:	GA
Zip	:	31823-0084
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5700 SPRING ST
Second Line	:
City	:	WARM SPRINGS
State	:	GA
Zip	:	31830-2164
Country	:	US
Telephone Number	:	229-310-1844
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARJORIE REESE
Credential	:
Telephone Number	:	229-310-1844

Provider Enumeration Date	:	12/16/2020
Last Update Date	:	12/16/2020

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