Healthcare Provider Details

I. General information

NPI: 1356997746
Provider Name (Legal Business Name): PALMETTO THERAPIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7436 FOREST CT STE 102
IRMO SC
29063-2856
US

IV. Provider business mailing address

244 MIDWAY RD
LEXINGTON SC
29072-9303
US

V. Phone/Fax

Practice location:
  • Phone: 803-318-7272
  • Fax: 803-318-7272
Mailing address:
  • Phone: 803-318-7272
  • Fax: 803-708-7301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ERVIN BEASLEY
Title or Position: OWNER
Credential: LPC
Phone: 803-318-7272