=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447073291
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNSELING SUPPORT SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2024
-----------------------------------------------------
Last Update Date | 10/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 97 APPLE ST
-----------------------------------------------------
City | TINTON FALLS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07724-2637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-337-8323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 SHREWSBURY DR
-----------------------------------------------------
City | LONG BRANCH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07740-7619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-337-8323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | TAHARKA SANKARA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-337-8323
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------