Provider Demographics
NPI:1154047702
Name:TRAILSIDE COUNSELING
Entity type:Organization
Organization Name:TRAILSIDE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:EIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-216-7010
Mailing Address - Street 1:164 MIDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-1864
Mailing Address - Country:US
Mailing Address - Phone:864-216-7010
Mailing Address - Fax:
Practice Address - Street 1:6715 STATE PARK RD
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-1831
Practice Address - Country:US
Practice Address - Phone:864-216-7010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1467052530Medicaid