Provider Demographics
NPI:1497453187
Name:LSBF PROFESSIONAL COUNSELING SERVICES, PLLC
Entity Type:Organization
Organization Name:LSBF PROFESSIONAL COUNSELING SERVICES, PLLC
Other - Org Name:ELLIE MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF MARKETING AND OUTREACH
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYANT
Authorized Official - Middle Name:
Authorized Official - Last Name:FORIEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-266-3289
Mailing Address - Street 1:8575 SHEPPARDS RUN DR
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7395
Mailing Address - Country:US
Mailing Address - Phone:336-266-3289
Mailing Address - Fax:
Practice Address - Street 1:250 EXECUTIVE PARK BLVD STE 120
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1534
Practice Address - Country:US
Practice Address - Phone:336-266-3289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-21
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty