Provider Demographics
NPI:1528893591
Name:ICU CHRISTIAN COUNSELING SERVICES
Entity type:Organization
Organization Name:ICU CHRISTIAN COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TEDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:252-256-0465
Mailing Address - Street 1:313 CHESTNUT OAK PL
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-5196
Mailing Address - Country:US
Mailing Address - Phone:252-256-0465
Mailing Address - Fax:
Practice Address - Street 1:4 CONSULTANT PL STE B
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6338
Practice Address - Country:US
Practice Address - Phone:919-442-8481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-07
Last Update Date:2024-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty