MEDICARE: MR. ANTAWN MAURICE POLITE LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	4788	SC

General Provider Information

NPI Number	:	1104026525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANTAWN MAURICE POLITE LPC

Provider Business Mailing Address
First Line	:	1231 MOSSTREE RD
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29405-5219
Country	:	US
Telephone Number	:	843-991-5015
Fax Number	:	843-884-1287

Provider Business Practice Location Address
First Line	:	1231 MOSSTREE RD
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29405-5219
Country	:	US
Telephone Number	:	843-991-5015
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2007
Last Update Date	:	05/12/2008

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