Healthcare Provider Details

I. General information

NPI: 1134557887
Provider Name (Legal Business Name): CALVIN BRYAN VACCHIO SR. PH.D., NCC, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 FOREST DR STE C
COLUMBIA SC
29204-4146
US

IV. Provider business mailing address

208 HILLWICK DR
GASTON SC
29053-8832
US

V. Phone/Fax

Practice location:
  • Phone: 803-403-8469
  • Fax: 803-403-9979
Mailing address:
  • Phone: 803-240-8841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5523
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: