Provider Demographics
NPI:1417283524
Name:PURE SERENITY CONSULTANT AND COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:PURE SERENITY CONSULTANT AND COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:COGDELL-QUICK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:843-687-4183
Mailing Address - Street 1:2550 KINGSTON DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-6423
Mailing Address - Country:US
Mailing Address - Phone:843-687-4183
Mailing Address - Fax:
Practice Address - Street 1:112 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:SC
Practice Address - Zip Code:29532-3204
Practice Address - Country:US
Practice Address - Phone:843-687-4183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
SC0603302101YA0400X
SC4711101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty