Organization
PROVISIONS COUNSELING SERVICES LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SHIRICKA LASHAYE FAIR LMFT (EXECUTIVE DIRECTOR)
(704) 906-5558
Entity
Organization
Contact information
Practice address
6 EXECUTIVE CT, LAKE WYLIE, SC 29710-9338
(704) 906-5558
Mailing address
5115 MINTVALE DR, CHARLOTTE, NC 28269-1689
(704) 906-5558
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
1484
NC
251S00000X
Community/Behavioral Health Agency
Primary
4611
SC
Other
Enumeration date
07/20/2015
Last updated
07/20/2015
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