Healthcare Provider Details

I. General information

NPI: 1710503784
Provider Name (Legal Business Name): INNER BANKS COUNSELING INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 11/03/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 PINE LN
WASHINGTON NC
27889-9674
US

IV. Provider business mailing address

305 PINE LN
WASHINGTON NC
27889-9674
US

V. Phone/Fax

Practice location:
  • Phone: 252-402-0234
  • Fax:
Mailing address:
  • Phone: 252-402-0234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. MELANIE EBORN TYNDALL
Title or Position: OWNER
Credential: MSW LCSW
Phone: 252-402-0234