1760188155 NPI number — COMPASSIONATE COUNSELING & SUPPORT SERVICES, LLC

Table of content: (NPI 1760188155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760188155 NPI number — COMPASSIONATE COUNSELING & SUPPORT SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPASSIONATE COUNSELING & SUPPORT SERVICES, LLC
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:
1760188155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 BLUE MOON XING
Provider Second Line Business Mailing Address:
SUITE 3, UNIT 114
Provider Business Mailing Address City Name:
POOLER
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31322-9798
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-682-1383
Provider Business Mailing Address Fax Number:
912-219-2285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 CREEKSIDE CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLABELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31308-7231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-682-1383
Provider Business Practice Location Address Fax Number:
912-219-2285
Provider Enumeration Date:
02/07/2023

Additional Information

Authorized Official

Authorized Official Last Name:
CORPREW
Authorized Official First Name:
TABRIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
912-682-1383

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: LPC0113110 . This is a "LICENSED PROFESSIONAL COUNSELOR" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com