MEDICARE: MISS JULIA TYESA MCCLARY LPC, CAC

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	5157	SC

General Provider Information

NPI Number	:	1558655506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JULIA TYESA MCCLARY LPC, CAC

Provider Business Mailing Address
First Line	:	PO BOX 6703
Second Line	:
City	:	SPARTANBURG
State	:	SC
Zip	:	29304-6703
Country	:	US
Telephone Number	:	864-580-9929
Fax Number	:

Provider Business Practice Location Address
First Line	:	187 W BROAD ST
Second Line	:
City	:	SPARTANBURG
State	:	SC
Zip	:	29306-3234
Country	:	US
Telephone Number	:	864-580-9929
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2011
Last Update Date	:	06/04/2012

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