MEDICARE: COLONIAL FAMILY PRACTICE, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	101YM0800X	Mental Health Counselor
4	101YP2500X	Professional Counselor
5	2084P0804X	Child & Adolescent Psychiatry Physician

General Provider Information

NPI Number	:	1336810175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLONIAL FAMILY PRACTICE, LLC

Provider Business Mailing Address
First Line	:	674 W LIBERTY ST
Second Line	:
City	:	SUMTER
State	:	SC
Zip	:	29150-4882
Country	:	US
Telephone Number	:	803-773-5227
Fax Number	:	803-757-4010

Provider Business Practice Location Address
First Line	:	696 BULTMAN DR.
Second Line	:
City	:	SUMTER
State	:	SC
Zip	:	29150-2549
Country	:	US
Telephone Number	:	803-773-5227
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	STEPHANIE KNIGHT DISHER
Credential	:
Telephone Number	:	803-773-5227

Provider Enumeration Date	:	09/22/2021
Last Update Date	:	09/22/2021

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