Provider Demographics
NPI:1194864975
Name:SOUTHLAKE COUNSELING & CONSULTING
Entity Type:Organization
Organization Name:SOUTHLAKE COUNSELING & CONSULTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:B
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:704-896-7776
Mailing Address - Street 1:903 NORTHEAST DR STE 201
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-7438
Mailing Address - Country:US
Mailing Address - Phone:704-896-7776
Mailing Address - Fax:704-896-0992
Practice Address - Street 1:903 NORTHEAST DR STE 201
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-7438
Practice Address - Country:US
Practice Address - Phone:704-896-7776
Practice Address - Fax:704-896-0992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0023621041C0700X
NCC0045741041C0700X
NCC0055101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty