Healthcare Provider Details

I. General information

NPI: 1427301092
Provider Name (Legal Business Name): JOURNEY REVEALED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 FIRST BAXTER XING SUITE 204
FORT MILL SC
29708-8948
US

IV. Provider business mailing address

44429 ORIOLE DR UNIT 101
INDIAN LAND SC
29707-5947
US

V. Phone/Fax

Practice location:
  • Phone: 803-431-0734
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: LAURI MAZE-DAVIS
Title or Position: MANAGER
Credential: APRN
Phone: 803-431-0734