Basic Information
| Provider Information | |||||||||
| NPI: | 1104372424 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOSTIC COUNSELING & CONSULTING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 207 CAROLYNS MILL PL | ||||||||
| Address2: | |||||||||
| City: | ROCKINGHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283797986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859678396 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 E BROAD AVE | ||||||||
| Address2: | SUITE 18 | ||||||||
| City: | ROCKINGHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283794382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859678396 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2016 | ||||||||
| LastUpdateDate: | 08/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | BOSTIC | ||||||||
| AuthorizedOfficialFirstName: | TAVARES | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5859678396 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C010090 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.