=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578949160
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVATIVE COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2015
-----------------------------------------------------
Last Update Date | 11/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 E MOREHEAD ST SUITE 20 - L
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28204-2850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-272-7859
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 E MOREHEAD ST SUITE 20-L
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28204-2850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-578-7543
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | TAMBGRA JUANETTE BROADAWAY
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 704-578-7543
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 8319
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------