Basic Information
| Provider Information | |||||||||
| NPI: | 1114185733 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERFACE COUNSELING & COUSULTING INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 SUNSET ST | ||||||||
| Address2: | |||||||||
| City: | WEAVERVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287879462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103895371 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 SUNSET ST | ||||||||
| Address2: | |||||||||
| City: | WEAVERVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287879462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103895371 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2008 | ||||||||
| LastUpdateDate: | 03/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | SAWYER | ||||||||
| AuthorizedOfficialFirstName: | GLENDA | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9103895371 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C001803 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6002868 | 05 | NC | MEDICAID | 327766 | 01 | NC | MHN | OTHER | 74652 | 01 | NC | BLUE CROSS/BLUE SHEILD | OTHER |