MEDICARE: EXECUTIVE COUNSELING OF TEGA CAY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1386357994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXECUTIVE COUNSELING OF TEGA CAY, LLC

Provider Business Mailing Address
First Line	:	3921 CALIPER PL
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-8380
Country	:	US
Telephone Number	:	704-388-2710
Fax Number	:

Provider Business Practice Location Address
First Line	:	3921 CALIPER PL
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-8380
Country	:	US
Telephone Number	:	803-487-6837
Fax Number	:

Authorized Official
Title or Position	:	OWNER, CLINICAL DIRECTOR
Name	:	MS. MILDRED BENNETT TILLMAN
Credential	:	LCMHC-S, LPC
Telephone Number	:	704-388-2710

Provider Enumeration Date	:	12/28/2022
Last Update Date	:	11/20/2024

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