Organization
INNOVATIVE COUNSELING SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TAMBGRA JUANETTE BROADAWAY LPC (CLINICAL DIRECTOR)
(704) 578-7543
Entity
Organization
Contact information
Practice address
1200 E MOREHEAD ST, SUITE 20 - L, CHARLOTTE, NC 28204-2850
(980) 272-7859
Mailing address
1200 E MOREHEAD ST, SUITE 20-L, CHARLOTTE, NC 28204-2850
(704) 578-7543
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
8319
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
61046900
—
NC
Enumeration date
08/05/2015
Last updated
11/23/2016
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