Provider Demographics
NPI:1013316918
Name:COGNITIVE BEHAVIORAL CLINIC LLC
Entity Type:Organization
Organization Name:COGNITIVE BEHAVIORAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDMOND
Authorized Official - Last Name:GARVEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:LPC
Authorized Official - Phone:843-450-0636
Mailing Address - Street 1:9403 HIGHWAY 707
Mailing Address - Street 2:SUITE B
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-7758
Mailing Address - Country:US
Mailing Address - Phone:843-450-0636
Mailing Address - Fax:843-215-4561
Practice Address - Street 1:9403 HIGHWAY 707
Practice Address - Street 2:SUITE B
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7758
Practice Address - Country:US
Practice Address - Phone:843-450-0636
Practice Address - Fax:843-215-4561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4121101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty