=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154047702
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRAILSIDE COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2022
-----------------------------------------------------
Last Update Date | 10/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6715 STATE PARK RD
-----------------------------------------------------
City | TRAVELERS REST
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29690-1831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-216-7010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 164 MIDWOOD RD
-----------------------------------------------------
City | TRAVELERS REST
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29690-1864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-216-7010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | COURTNEY EIDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 864-216-7010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------