Provider Demographics
NPI:1598242554
Name:FORTITUDE CONSULTING, COUNSELING & SUPERVISION SERVICES, LLC
Entity Type:Organization
Organization Name:FORTITUDE CONSULTING, COUNSELING & SUPERVISION SERVICES, LLC
Other - Org Name:CHANA A. SKELTON, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO/REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:CHANA
Authorized Official - Middle Name:ASHLAN
Authorized Official - Last Name:LAND
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LPCS
Authorized Official - Phone:864-952-1219
Mailing Address - Street 1:1085 OLD CLEMSON HIGHWAY SUITE E, #111
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29672-8029
Mailing Address - Country:US
Mailing Address - Phone:864-952-1219
Mailing Address - Fax:
Practice Address - Street 1:530 BY PASS 123 STE E2
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-0860
Practice Address - Country:US
Practice Address - Phone:864-952-1219
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5087101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC1934Medicaid