Provider Demographics
NPI:1881843647
Name:INDIVIDUAL, COUPLE, AND FAMILY SERVICES
Entity Type:Organization
Organization Name:INDIVIDUAL, COUPLE, AND FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:RIVENBARK
Authorized Official - Suffix:
Authorized Official - Credentials:LCAS, LPC, LMFT, MAC
Authorized Official - Phone:980-254-5401
Mailing Address - Street 1:1850 E 3RD ST
Mailing Address - Street 2:SUITE 125
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3238
Mailing Address - Country:US
Mailing Address - Phone:980-254-5401
Mailing Address - Fax:
Practice Address - Street 1:1850 E 3RD ST
Practice Address - Street 2:SUITE 125
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3238
Practice Address - Country:US
Practice Address - Phone:980-254-5401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS 1243251S00000X
NCLPC 5490251S00000X
NCLMFT 965251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health