Provider Demographics
NPI:1831244094
Name:PRODIGIOUS COUNSELING SERVICES, LLC
Entity type:Organization
Organization Name:PRODIGIOUS COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:FAISON
Authorized Official - Suffix:
Authorized Official - Credentials:LCAS
Authorized Official - Phone:252-433-0300
Mailing Address - Street 1:208 N GARNETT ST
Mailing Address - Street 2:SUITE F.
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-4673
Mailing Address - Country:US
Mailing Address - Phone:252-433-0300
Mailing Address - Fax:252-433-8054
Practice Address - Street 1:208 N GARNETT ST
Practice Address - Street 2:SUITE F.
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-4673
Practice Address - Country:US
Practice Address - Phone:252-433-0300
Practice Address - Fax:252-433-8054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC875251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health