Provider Demographics
NPI:1396215737
Name:SOUTHERLAND TREATMENT AND REHAB(STAR) COUNSELING&CONSULTING SVCS, PLLC
Entity Type:Organization
Organization Name:SOUTHERLAND TREATMENT AND REHAB(STAR) COUNSELING&CONSULTING SVCS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LPCS
Authorized Official - Prefix:
Authorized Official - First Name:TIMEKA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SOUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:LPCS, CSOTS, TFCBT
Authorized Official - Phone:336-745-7179
Mailing Address - Street 1:206 FAIR OAKS LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-3178
Mailing Address - Country:US
Mailing Address - Phone:336-745-7179
Mailing Address - Fax:336-842-3055
Practice Address - Street 1:206 FAIR OAKS LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-3178
Practice Address - Country:US
Practice Address - Phone:336-745-7179
Practice Address - Fax:336-842-3055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty