Healthcare Provider Details

I. General information

NPI: 1265672844
Provider Name (Legal Business Name): STATE-BOUND TREATMENT SERVICES LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2009
Last Update Date: 02/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 SUGAR CREEK ROAD
GREER SC
29650
US

IV. Provider business mailing address

112 SUGAR CREEK ROAD
GREER SC
29650
US

V. Phone/Fax

Practice location:
  • Phone: 864-906-1043
  • Fax:
Mailing address:
  • Phone: 864-906-1043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. GEORGE JAMES BRAVAKIS
Title or Position: PROGRAMDIRECTOR/LEAD CLINICAL STAFF
Credential: LICENSED MASTER OF S
Phone: 864-906-1043