Provider Demographics
NPI:1457861072
Name:PROVISIONS COUNSELING SERVICES
Entity Type:Organization
Organization Name:PROVISIONS COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRICKA
Authorized Official - Middle Name:LASHAYE
Authorized Official - Last Name:FAIR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMFT
Authorized Official - Phone:704-750-0655
Mailing Address - Street 1:5115 MINTVALE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-1689
Mailing Address - Country:US
Mailing Address - Phone:704-750-0655
Mailing Address - Fax:
Practice Address - Street 1:1000 BAXTER ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2859
Practice Address - Country:US
Practice Address - Phone:704-750-0655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1484101Y00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1326339185Medicaid