MEDICARE: ISLAND TRANSITIONS COUNSELING AND CONSULTING, 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
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1396317145
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISLAND TRANSITIONS COUNSELING AND CONSULTING, LLC.

Provider Business Mailing Address
First Line	:	3226 MAYBANK HWY UNIT A
Second Line	:
City	:	JOHNS ISLAND
State	:	SC
Zip	:	29455-4858
Country	:	US
Telephone Number	:	618-559-1124
Fax Number	:

Provider Business Practice Location Address
First Line	:	3226 MAYBANK HWY UNIT A
Second Line	:
City	:	JOHNS ISLAND
State	:	SC
Zip	:	29455-4858
Country	:	US
Telephone Number	:	618-559-1124
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CLINICIAN
Name	:	MS. KATHRYN ELAINE ROOSEVELT
Credential	:	LISW-CP
Telephone Number	:	618-559-1124

Provider Enumeration Date	:	07/12/2021
Last Update Date	:	07/12/2021

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