Healthcare Provider Details

I. General information

NPI: 1902403116
Provider Name (Legal Business Name): PIECES 2 PEACE WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 BELLEVIEW ST STE 103
COLUMBIA SC
29201-1839
US

IV. Provider business mailing address

PO BOX 9054
COLUMBIA SC
29290-0054
US

V. Phone/Fax

Practice location:
  • Phone: 803-250-5198
  • Fax:
Mailing address:
  • Phone: 803-250-5198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANNA B. GANTT-GORDON
Title or Position: CO-OWNER
Credential: LPC
Phone: 803-250-5198