Healthcare Provider Details

I. General information

NPI: 1467051953
Provider Name (Legal Business Name): DEONTAY ADRAIN WINCHESTER LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S KAMINSKI ST STE 213
GEORGETOWN SC
29440-3435
US

IV. Provider business mailing address

2829 ETON ST
MYRTLE BEACH SC
29579-6711
US

V. Phone/Fax

Practice location:
  • Phone: 843-932-7217
  • Fax:
Mailing address:
  • Phone: 843-202-5789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number13807
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number13807
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13807
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number13807
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number13807
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code102X00000X
TaxonomyPoetry Therapist
License Number13807
License Number StateSC
# 7
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13807
License Number StateSC
# 8
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number13807
License Number StateSC
# 9
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13807
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: