Healthcare Provider Details

I. General information

NPI: 1972845196
Provider Name (Legal Business Name): SOUTH CAROLINA MENTOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 03/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 CARRIAGE LN SUITE 302
CHARLESTON SC
29407-6065
US

IV. Provider business mailing address

4 CARRIAGE LN SUITE 302
CHARLESTON SC
29407-6065
US

V. Phone/Fax

Practice location:
  • Phone: 843-573-1905
  • Fax: 843-573-1926
Mailing address:
  • Phone: 843-573-1905
  • Fax: 843-573-1926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number1-13-12976
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1-13-12976
License Number StateSC

VIII. Authorized Official

Name: MS. JENNIFER MARY POOLE
Title or Position: BEHAVIORAL CONSULTANT
Credential: BCBA
Phone: 843-513-0040