MEDICARE: HEART STONE 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	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1902533714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEART STONE COUNSELING LLC

Provider Business Mailing Address
First Line	:	967 BROADWAY STE 2
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-4263
Country	:	US
Telephone Number	:	207-613-2470
Fax Number	:

Provider Business Practice Location Address
First Line	:	967 BROADWAY STE 2
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-4263
Country	:	US
Telephone Number	:	207-613-2470
Fax Number	:

Authorized Official
Title or Position	:	OWNER / THERAPIST
Name	:	EMILY A VAN CANNON
Credential	:	LCPC, LADC, CCS
Telephone Number	:	207-613-2470

Provider Enumeration Date	:	08/02/2022
Last Update Date	:	08/02/2022

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Directions to “HEART STONE COUNSELING LLC ” Practice Location

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