Healthcare Provider Details

I. General information

NPI: 1427650050
Provider Name (Legal Business Name): PALMETTO PSYCH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9330 MEDICAL PLAZA DR
CHARLESTON SC
29406-9104
US

IV. Provider business mailing address

222 W ONTARIO ST STE 315
CHICAGO IL
60654-3652
US

V. Phone/Fax

Practice location:
  • Phone: 706-831-4837
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: HETALBABU THAKORE
Title or Position: SOLE MEMBER
Credential:
Phone: 203-901-2493