Healthcare Provider Details

I. General information

NPI: 1457522658
Provider Name (Legal Business Name): DR. MICHAEL NEBOSCHICK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 PARAN OAKS DR
CHARLESTON SC
29414-9046
US

IV. Provider business mailing address

838 PARAN OAKS DR
CHARLESTON SC
29414-9046
US

V. Phone/Fax

Practice location:
  • Phone: 843-852-9016
  • Fax: 843-763-7246
Mailing address:
  • Phone: 843-852-9016
  • Fax: 843-763-7246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number328
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number328
License Number StateSC

VIII. Authorized Official

Name: DR. MICHAEL ROBERT NEBOSCHICK
Title or Position: LICENSED PSYCHOLOGIST
Credential: PHD
Phone: 843-852-9016