Provider Demographics
NPI:1386357994
Name:EXECUTIVE COUNSELING OF TEGA CAY, LLC
Entity type:Organization
Organization Name:EXECUTIVE COUNSELING OF TEGA CAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:BENNETT
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC-S, LPC
Authorized Official - Phone:704-388-2710
Mailing Address - Street 1:3921 CALIPER PL
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8380
Mailing Address - Country:US
Mailing Address - Phone:704-388-2710
Mailing Address - Fax:
Practice Address - Street 1:3921 CALIPER PL
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8380
Practice Address - Country:US
Practice Address - Phone:803-487-6837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-28
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty