MEDICARE: INTEGRATIVE COUNSELING SERVICES 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	6401010688	MI

General Provider Information

NPI Number	:	1598939274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATIVE COUNSELING SERVICES LLC

Provider Business Mailing Address
First Line	:	19900 E 10 MILE RD
Second Line	:	SUITE 102
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-4412
Country	:	US
Telephone Number	:	586-491-2040
Fax Number	:

Provider Business Practice Location Address
First Line	:	19900 E 10 MILE RD
Second Line	:	SUITE 102
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-4412
Country	:	US
Telephone Number	:	586-491-2040
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	MRS. BRENDA LEE JACKSON
Credential	:	LLPC
Telephone Number	:	18004994169

Provider Enumeration Date	:	04/15/2008
Last Update Date	:	05/21/2010

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