Healthcare Provider Details

I. General information

NPI: 1295127868
Provider Name (Legal Business Name): PAWEL POTYLICKI MS, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2015
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 COLONIAL DR
COLUMBIA SC
29203-6818
US

IV. Provider business mailing address

2715 COLONIAL DR
COLUMBIA SC
29203-6818
US

V. Phone/Fax

Practice location:
  • Phone: 803-783-0303
  • Fax: 803-783-0955
Mailing address:
  • Phone: 803-783-0303
  • Fax: 803-783-0955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6056
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: