Provider Demographics
NPI:1881623973
Name:SOUTHERN PROFESSIONAL COUNSELING SERVICES, LLC
Entity type:Organization
Organization Name:SOUTHERN PROFESSIONAL COUNSELING SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:B
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:910-862-4151
Mailing Address - Street 1:PO BOX 1894
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337-1894
Mailing Address - Country:US
Mailing Address - Phone:910-862-4151
Mailing Address - Fax:910-862-3470
Practice Address - Street 1:306 WEST BROAD ST.
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337-1894
Practice Address - Country:US
Practice Address - Phone:910-862-4151
Practice Address - Fax:910-862-3470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005118Medicaid
NC6005118Medicaid