Provider Demographics
NPI:1740753730
Name:SOUTHFORK COUNSELING CENTER
Entity Type:Organization
Organization Name:SOUTHFORK COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN/ CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:TALLENT
Authorized Official - Suffix:
Authorized Official - Credentials:MA, EDS, LPC, NCC
Authorized Official - Phone:980-284-2159
Mailing Address - Street 1:701 S LAUREL ST STE 3
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28092-3654
Mailing Address - Country:US
Mailing Address - Phone:980-284-2159
Mailing Address - Fax:980-284-2205
Practice Address - Street 1:701 S LAUREL ST STE 3
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-3654
Practice Address - Country:US
Practice Address - Phone:704-740-7044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-02
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty