Healthcare Provider Details

I. General information

NPI: 1588816870
Provider Name (Legal Business Name): SANKOFA THERAPEUTIC CONCEPTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 BEN CASEY DR STE 102
FORT MILL SC
29708-6567
US

IV. Provider business mailing address

2879 HIGHWAY 160 W PMB 4408
FORT MILL SC
29708-8581
US

V. Phone/Fax

Practice location:
  • Phone: 803-386-3064
  • Fax: 866-591-1741
Mailing address:
  • Phone: 803-386-3064
  • Fax: 866-591-1741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8780
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF0704137
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number4345
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC005480
License Number StateNC

VIII. Authorized Official

Name: MS. DONITA P HOLMES
Title or Position: OWNER/CLINICAL CONSULTANT
Credential: LISW-CP
Phone: 803-207-0993