Provider Demographics
NPI:1225245665
Name:KOESTLINE, INC.
Entity Type:Organization
Organization Name:KOESTLINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC
Authorized Official - Prefix:MR
Authorized Official - First Name:W.
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:KOESTLINE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MA
Authorized Official - Phone:803-781-1565
Mailing Address - Street 1:1509 QUAIL VLY W
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-1536
Mailing Address - Country:US
Mailing Address - Phone:803-781-1565
Mailing Address - Fax:
Practice Address - Street 1:6952 SAINT ANDREWS RD
Practice Address - Street 2:ST. ANDREWS PRESBYTERIAN CHURCH
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1143
Practice Address - Country:US
Practice Address - Phone:803-727-3460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC149101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty