MEDICARE: NOVA COUNSELING ALTERNATIVES 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	1041C0700X	Clinical Social Worker	34003588A	IN
2	1041C0700X	Clinical Social Worker	34004562A	IN
3	1041C0700X	Clinical Social Worker	1042	KY
4	106H00000X	Marriage & Family Therapist	35001423A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
6	IN2168	OTHER	IN	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11459548	OTHER	IN	WENDY CAQH
2	11608101	OTHER		CAQH E. HATFIELD
3	1477559334	OTHER		NPI WENDY WILLIS
4	11459226	OTHER		CAQH S. WISMAN
5	1316944432	OTHER		NPI SELENA WISMAN
7	1467459446	OTHER		NPI-ELENA HATFIELD

General Provider Information

NPI Number	:	1972710481
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVA COUNSELING ALTERNATIVES LLC

Provider Business Mailing Address
First Line	:	PO BOX 413
Second Line	:
City	:	NEW ALBANY
State	:	IN
Zip	:	47151-0413
Country	:	US
Telephone Number	:	812-206-3291
Fax Number	:

Provider Business Practice Location Address
First Line	:	1941 E SPRING ST
Second Line	:
City	:	NEW ALBANY
State	:	IN
Zip	:	47150-1658
Country	:	US
Telephone Number	:	812-206-3291
Fax Number	:	812-206-3296

Authorized Official
Title or Position	:	OWNER
Name	:	SELENA B. WISMAN
Credential	:	LMFT
Telephone Number	:	812-206-3291

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	12/19/2014

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