Healthcare Provider Details

I. General information

NPI: 1093300428
Provider Name (Legal Business Name): MORGAN T MENDENHALL BCABA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2021
Last Update Date: 06/09/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 W BUTLER RD
GREENVILLE SC
29607-4833
US

IV. Provider business mailing address

219 GERALD DR
SIMPSONVILLE SC
29681-4111
US

V. Phone/Fax

Practice location:
  • Phone: 864-575-9918
  • Fax:
Mailing address:
  • Phone: 864-757-9918
  • Fax: 864-757-9921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number02011676
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: