Healthcare Provider Details

I. General information

NPI: 1306691019
Provider Name (Legal Business Name): COUNSELING CONNECTIONS CLINICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 LOOKOUT PT
SANFORD NC
27332-9666
US

IV. Provider business mailing address

49 LOOKOUT PT
SANFORD NC
27332-9666
US

V. Phone/Fax

Practice location:
  • Phone: 910-547-8567
  • Fax:
Mailing address:
  • Phone: 910-547-8567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: KIM KNOELLER
Title or Position: PROVIDER
Credential: LCSW
Phone: 910-547-8567