Healthcare Provider Details

I. General information

NPI: 1366911919
Provider Name (Legal Business Name): INTEGRATIVE THERAPEUTIC COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 TYVOLA RD STE 218
CHARLOTTE NC
28217-3515
US

IV. Provider business mailing address

607 PINE TREE ES DR
SALISBURY NC
28144-0517
US

V. Phone/Fax

Practice location:
  • Phone: 540-320-2859
  • Fax:
Mailing address:
  • Phone: 540-320-2859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. SHEENA ILEAN HASTY
Title or Position: CEO
Credential: LCASA-23287
Phone: 540-320-2859