MEDICARE: ICU CHRISTIAN COUNSELING SERVICES

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	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1528893591
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ICU CHRISTIAN COUNSELING SERVICES

Provider Business Mailing Address
First Line	:	313 CHESTNUT OAK PL
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27704-5196
Country	:	US
Telephone Number	:	252-256-0465
Fax Number	:

Provider Business Practice Location Address
First Line	:	4 CONSULTANT PL STE B
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27707-6338
Country	:	US
Telephone Number	:	919-442-8481
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TEDRA COOK
Credential	:	LCSW
Telephone Number	:	252-256-0465

Provider Enumeration Date	:	09/07/2024
Last Update Date	:	09/07/2024

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