Provider Demographics
NPI:1245627769
Name:ELITE COMMUNITY COUNSELING
Entity type:Organization
Organization Name:ELITE COMMUNITY COUNSELING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:SEAN
Authorized Official - Last Name:ETHERIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSE PROFESSIONAL
Authorized Official - Phone:843-672-7096
Mailing Address - Street 1:274 SEDGEWICK DR APT 101
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8170
Mailing Address - Country:US
Mailing Address - Phone:404-655-9802
Mailing Address - Fax:
Practice Address - Street 1:212 W MCGREGOR ST
Practice Address - Street 2:
Practice Address - City:PAGELAND
Practice Address - State:SC
Practice Address - Zip Code:29728-2137
Practice Address - Country:US
Practice Address - Phone:843-672-7096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2025-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 251S00000X
SC6059101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty