Healthcare Provider Details

I. General information

NPI: 1073054847
Provider Name (Legal Business Name): COLUMBIA NORTHEAST COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9570 TWO NOTCH RD SUITE #8
COLUMBIA SC
29223-4308
US

IV. Provider business mailing address

PO BOX 25453
COLUMBIA SC
29224-5453
US

V. Phone/Fax

Practice location:
  • Phone: 803-782-5556
  • Fax: 803-788-0914
Mailing address:
  • Phone: 803-782-5556
  • Fax: 803-788-0914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3157
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8950
License Number StateSC

VIII. Authorized Official

Name: SUZANNE W PEEBLES
Title or Position: OWNER/MENTAL HEALTH COUNSELOR
Credential: M.ED, LPC
Phone: 803-782-5556