Healthcare Provider Details

I. General information

NPI: 1942644091
Provider Name (Legal Business Name): PSYCHOLOGY SERVICES CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 DEVINE ST SUITE 100
COLUMBIA SC
29205-2418
US

IV. Provider business mailing address

2221 DEVINE ST SUITE 100
COLUMBIA SC
29205-2418
US

V. Phone/Fax

Practice location:
  • Phone: 803-734-0378
  • Fax: 803-734-0379
Mailing address:
  • Phone: 803-734-0378
  • Fax: 803-734-0379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateSC

VIII. Authorized Official

Name: DR. MICHELE BURNETTE
Title or Position: DIRECTOR
Credential: PH.D.
Phone: 803-734-0378