=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174556815
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE WATER COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 397 BLAKE ST
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29302-1572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-253-9089
-----------------------------------------------------
Fax | 864-591-1232
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 397 BLAKE ST
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29302-1572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-253-9089
-----------------------------------------------------
Fax | 864-591-1232
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | TIMOTHY L HOLLAND
-----------------------------------------------------
Credential | D.MIN., LPC, LMFT
-----------------------------------------------------
Telephone | 864-253-9089
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 1818
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------