MEDICARE: DISRUPTIVE THINKING COUNSELING 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1568343515
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DISRUPTIVE THINKING COUNSELING LLC

Provider Business Mailing Address
First Line	:	45 MOULTRIE ST
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29403-4132
Country	:	US
Telephone Number	:	843-437-2836
Fax Number	:

Provider Business Practice Location Address
First Line	:	45 MOULTRIE ST
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29403-4132
Country	:	US
Telephone Number	:	843-437-2836
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS OWNER
Name	:	SHAMA TICSHERA WINSTON-FORD
Credential	:	LPC
Telephone Number	:	843-437-2836

Provider Enumeration Date	:	09/08/2025
Last Update Date	:	09/08/2025

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