Healthcare Provider Details

I. General information

NPI: 1124807847
Provider Name (Legal Business Name): MENDED THERAPY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2023
Last Update Date: 09/22/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 CENTRAL AVE STE 5
GOOSE CREEK SC
29445-3079
US

IV. Provider business mailing address

108 CENTRAL AVE STE 5
GOOSE CREEK SC
29445-3079
US

V. Phone/Fax

Practice location:
  • Phone: 803-450-6479
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MCCRAE CARROLL
Title or Position: THERAPIST
Credential: LPCA
Phone: 803-450-6479