Healthcare Provider Details

I. General information

NPI: 1760853410
Provider Name (Legal Business Name): INSIDE OUT COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 VILLAGE RD SW STE 2
SHALLOTTE NC
28470-3434
US

IV. Provider business mailing address

PO BOX 2352
SHALLOTTE NC
28459-2352
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-7377
  • Fax: 910-754-7378
Mailing address:
  • Phone: 910-754-7377
  • Fax: 910-754-7378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10093
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLPC 10093
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLCAS 3399
License Number StateNC

VIII. Authorized Official

Name: NICOLE ELLEN
Title or Position: OWNER/PROVIDER
Credential: LPC, LCAS
Phone: 910-754-7377