Healthcare Provider Details

I. General information

NPI: 1336624543
Provider Name (Legal Business Name): MILITARY SUPPLEMENTAL COUNSELING CENTER, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 GUM BRANCH RD STE 122
JACKSONVILLE NC
28540-6293
US

IV. Provider business mailing address

313 WALNUT ST STE 106
WILMINGTON NC
28401-4063
US

V. Phone/Fax

Practice location:
  • Phone: 336-345-5565
  • Fax:
Mailing address:
  • Phone: 336-345-5565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: GWEN C BORCYK
Title or Position: CO-OWNER
Credential: LCSW
Phone: 336-345-5565