Provider Demographics
NPI:1255877296
Name:KINGSBERRY COUNSELING SERVICES, PLLC
Entity type:Organization
Organization Name:KINGSBERRY COUNSELING SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:TRAVIS
Authorized Official - Last Name:THACKER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LCAS
Authorized Official - Phone:336-575-5948
Mailing Address - Street 1:PO BOX 30312
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27130-0312
Mailing Address - Country:US
Mailing Address - Phone:336-575-5948
Mailing Address - Fax:
Practice Address - Street 1:421 PAIGEBROOK DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-8744
Practice Address - Country:US
Practice Address - Phone:336-575-5948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-14
Last Update Date:2017-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20293101YA0400X
NC00115237225C00000X
NC9455101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorGroup - Multi-Specialty