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Organization
KINGSBERRY COUNSELING SERVICES, PLLC
Active
Organization
KINGSBERRY COUNSELING SERVICES, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JOHN TRAVIS THACKER LPC, LCAS (OWNER)
(336) 575-5948
Entity
Organization
Contact information
Practice address
421 PAIGEBROOK DR, WINSTON SALEM, NC 27106-8744
(336) 575-5948
Mailing address
PO BOX 30312, WINSTON SALEM, NC 27130-0312
(336) 575-5948
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
20293
NC
101YM0800X
Mental Health Counselor
Primary
9455
NC
225C00000X
Rehabilitation Counselor
00115237
NC
Other
Enumeration date
01/14/2017
Last updated
01/14/2017
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