MEDICARE: VIRGINIA L UNDERWOOD ADCP

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	ADC-311	SC

General Provider Information

NPI Number	:	1699432088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIRGINIA L UNDERWOOD ADCP

Provider Business Mailing Address
First Line	:	1187 HOLLAND RD
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29681-5710
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1187 HOLLAND RD
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29681-5710
Country	:	US
Telephone Number	:	844-959-4092
Fax Number	:

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

Provider Enumeration Date	:	11/21/2021
Last Update Date	:	11/21/2021

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