Healthcare Provider Details

I. General information

NPI: 1184082604
Provider Name (Legal Business Name): U-REAACH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2016
Last Update Date: 01/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 RED BLUFF STREET
CLIO SC
29525-4722
US

IV. Provider business mailing address

741 CRAIG CIR
BENNETTSVILLE SC
29512-2005
US

V. Phone/Fax

Practice location:
  • Phone: 843-586-0108
  • Fax: 843-586-0108
Mailing address:
  • Phone: 843-586-0108
  • Fax: 843-586-0108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1411038
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5249
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number5249
License Number StateSC

VIII. Authorized Official

Name: DR. DAMIEN EDWARD JOHNSON
Title or Position: OWNER
Credential: PH.D., LPC, CAC-II,
Phone: 843-586-0108