1689925562 NPI number — INTO THE LIGHT COUNSELING, INC.

Table of content: (NPI 1689925562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689925562 NPI number — INTO THE LIGHT COUNSELING, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTO THE LIGHT COUNSELING, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689925562
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1348
Provider Second Line Business Mailing Address:
PO BOX 1348
Provider Business Mailing Address City Name:
CLAYTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27528-1348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-271-0135
Provider Business Mailing Address Fax Number:
888-503-6822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
353 W 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAYTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27520-2336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-271-0135
Provider Business Practice Location Address Fax Number:
888-503-6822
Provider Enumeration Date:
10/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
EAVES
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/THERAPIST
Authorized Official Telephone Number:
919-271-0135

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C004198 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6003393 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 141C3 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2860031A . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".




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