Healthcare Provider Details

I. General information

NPI: 1538568233
Provider Name (Legal Business Name): RAKEYTA REAL SSP, LPES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 ELMWOOD AVE
COLUMBIA SC
29201-2150
US

IV. Provider business mailing address

7625 MAIN ST
GROVETOWN GA
30813-1217
US

V. Phone/Fax

Practice location:
  • Phone: 803-250-5109
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4816
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: