Provider Demographics
NPI:1942776943
Name:SOUTHPORT COUNSELING SERVICES, PLLC
Entity Type:Organization
Organization Name:SOUTHPORT COUNSELING SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYMRA
Authorized Official - Middle Name:F
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:828-385-1889
Mailing Address - Street 1:3960 EXECUTIVE PARK BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-8184
Mailing Address - Country:US
Mailing Address - Phone:910-854-0371
Mailing Address - Fax:910-854-0371
Practice Address - Street 1:3960 EXECUTIVE PARK BLVD STE 3
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-8184
Practice Address - Country:US
Practice Address - Phone:910-854-0371
Practice Address - Fax:910-854-0371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC79895OtherBCBSNC