Provider Demographics
NPI:1396257085
Name:CLEARWATERS COUNSELING SERVICES, LLC
Entity type:Organization
Organization Name:CLEARWATERS COUNSELING SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORPORATE COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:LILES
Authorized Official - Suffix:
Authorized Official - Credentials:MS,ED
Authorized Official - Phone:704-695-2391
Mailing Address - Street 1:PO BOX 1367
Mailing Address - Street 2:
Mailing Address - City:HAMLET
Mailing Address - State:NC
Mailing Address - Zip Code:28345-1367
Mailing Address - Country:US
Mailing Address - Phone:704-475-6442
Mailing Address - Fax:
Practice Address - Street 1:34 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HAMLET
Practice Address - State:NC
Practice Address - Zip Code:28345-3636
Practice Address - Country:US
Practice Address - Phone:704-475-6442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEARWATERS COUNSELING SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-02
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0000000OtherNO NUMBER
00000000000000OtherNO NUMBERS