Healthcare Provider Details

I. General information

NPI: 1164456844
Provider Name (Legal Business Name): DAVID MICKELL BA SOCIAL WORKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 GILWAY EXTENSION
HOLLY HILL SC
29059
US

IV. Provider business mailing address

2319 ST MATTHEWS ROAD
ORANGEBURG SC
29118
US

V. Phone/Fax

Practice location:
  • Phone: 803-496-3410
  • Fax: 803-496-9185
Mailing address:
  • Phone: 803-536-1571
  • Fax: 803-536-1463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: