Healthcare Provider Details

I. General information

NPI: 1659800167
Provider Name (Legal Business Name): SOUTHEASTERN SUCCESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 LYTTLETON ST
CAMDEN SC
29020-4412
US

IV. Provider business mailing address

PO BOX 2487
CAMDEN SC
29020-8009
US

V. Phone/Fax

Practice location:
  • Phone: 803-713-7979
  • Fax: 803-728-2200
Mailing address:
  • Phone: 803-729-5161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARY MYERS BRIDGES
Title or Position: OWNER
Credential: LPC
Phone: 803-713-7979