Healthcare Provider Details

I. General information

NPI: 1336568062
Provider Name (Legal Business Name): ASHLEY MACON LPC-I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 05/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3809 ROSEWOOD DR
COLUMBIA SC
29205-3533
US

IV. Provider business mailing address

PO BOX 4246
COLUMBIA SC
29240-4246
US

V. Phone/Fax

Practice location:
  • Phone: 803-786-1844
  • Fax: 803-754-7783
Mailing address:
  • Phone: 803-786-1844
  • Fax: 803-754-7783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6236
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: