Healthcare Provider Details

I. General information

NPI: 1942611066
Provider Name (Legal Business Name): COMMONGROUND COUNSELING AND LIFE COACHING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 SIX MILE CREEK RD
LANCASTER SC
29720-9719
US

IV. Provider business mailing address

242 SIX MILE CREEK RD
LANCASTER SC
29720-9719
US

V. Phone/Fax

Practice location:
  • Phone: 803-322-5242
  • Fax:
Mailing address:
  • Phone: 803-322-5242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5690
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5690
License Number StateSC

VIII. Authorized Official

Name: KEVIN JOHN PHILLIPS
Title or Position: DIRECTOR, CLINICAL COUNSELOR
Credential: MA, LPC-I
Phone: 803-322-5242