Healthcare Provider Details

I. General information

NPI: 1790935336
Provider Name (Legal Business Name): CENTER FOR PERSONAL GROWTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 B W THOMAS DR #125
FT. MILL SC
29708
US

IV. Provider business mailing address

150 B.W. THOMAS DRIVE #125
FT. MILL SC
29708
US

V. Phone/Fax

Practice location:
  • Phone: 803-517-9816
  • Fax: 803-548-5343
Mailing address:
  • Phone: 803-517-9816
  • Fax: 803-548-5343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6244
License Number StateSC

VIII. Authorized Official

Name: SALLY A SMITH
Title or Position: OFFICE MANAGER
Credential: SOCIAL WORKER
Phone: 803-283-3810