Provider Demographics
NPI:1104364835
Name:PREMIER COUNSELING GROUP PLLC
Entity Type:Organization
Organization Name:PREMIER COUNSELING GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAVARES
Authorized Official - Middle Name:ANTWAN
Authorized Official - Last Name:BOSTIC
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:585-967-8396
Mailing Address - Street 1:801 E BROAD AVE
Mailing Address - Street 2:STE 18
Mailing Address - City:ROCKINGHAM
Mailing Address - State:NC
Mailing Address - Zip Code:28379-4383
Mailing Address - Country:US
Mailing Address - Phone:585-967-8396
Mailing Address - Fax:910-491-9715
Practice Address - Street 1:201 STROMAN RD
Practice Address - Street 2:
Practice Address - City:MARSTON
Practice Address - State:NC
Practice Address - Zip Code:28363-9501
Practice Address - Country:US
Practice Address - Phone:585-967-8396
Practice Address - Fax:910-491-9715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health