Provider Demographics
NPI:1811371842
Name:PROVISIONS COUNSELING SERVICES LLC
Entity Type:Organization
Organization Name:PROVISIONS COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHIRICKA
Authorized Official - Middle Name:LASHAYE
Authorized Official - Last Name:FAIR
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:704-906-5558
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:704-906-5558
Mailing Address - Fax:
Practice Address - Street 1:6 EXECUTIVE CT
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-9338
Practice Address - Country:US
Practice Address - Phone:704-906-5558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4611251S00000X
NC1484251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health