Healthcare Provider Details

I. General information

NPI: 1396064382
Provider Name (Legal Business Name): PALMETTO PEDIATRIC OT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2010
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2427 OLD LEXINGTON HIGHWAY
CHAPIN SC
29036
US

IV. Provider business mailing address

2427 OLD LEXINGTON HIGHWAY
CHAPIN SC
29036
US

V. Phone/Fax

Practice location:
  • Phone: 803-319-7723
  • Fax: 803-941-7568
Mailing address:
  • Phone: 803-319-7723
  • Fax: 803-941-7568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number3240
License Number StateSC

VIII. Authorized Official

Name: HAYLEE D MITCHELL
Title or Position: OWNER, OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 803-319-7723