Provider Demographics
NPI:1528562477
Name:FORTENBERRY COUNSELING AND CONSULTING SERVICES, LLC.
Entity Type:Organization
Organization Name:FORTENBERRY COUNSELING AND CONSULTING SERVICES, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:TAYLA
Authorized Official - Middle Name:R
Authorized Official - Last Name:FORTENBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, EDS, LPC
Authorized Official - Phone:864-494-5462
Mailing Address - Street 1:111 MADISON RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SC
Mailing Address - Zip Code:29673-7915
Mailing Address - Country:US
Mailing Address - Phone:864-494-5462
Mailing Address - Fax:
Practice Address - Street 1:880 S PLEASANTBURG DR STE 4F
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2453
Practice Address - Country:US
Practice Address - Phone:864-494-5462
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6611101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC1840Medicaid