Provider Demographics
NPI:1891169819
Name:INDIVIDUALIZED COUNSELING OF ROANOKE LLC
Entity Type:Organization
Organization Name:INDIVIDUALIZED COUNSELING OF ROANOKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MISCO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:540-776-6466
Mailing Address - Street 1:3524 BRAMBLETON AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-6528
Mailing Address - Country:US
Mailing Address - Phone:540-776-6466
Mailing Address - Fax:
Practice Address - Street 1:3524 BRAMBLETON AVE STE 5
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-6528
Practice Address - Country:US
Practice Address - Phone:540-776-6466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040057981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty