Healthcare Provider Details

I. General information

NPI: 1265489793
Provider Name (Legal Business Name): THE CENTER FOR COUNSELING AND LIFE SKILL DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2006
Last Update Date: 01/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 S BLACKSTOCK RD
LANDRUM SC
29356-9136
US

IV. Provider business mailing address

1012 S BLACKSTOCK RD
LANDRUM SC
29356-9136
US

V. Phone/Fax

Practice location:
  • Phone: 864-457-4208
  • Fax: 864-457-2866
Mailing address:
  • Phone: 864-457-4208
  • Fax: 864-457-2866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC 3338
License Number StateSC

VIII. Authorized Official

Name: MS. TARA WEST HORNE
Title or Position: PRESIDENT/CLINICAL DIRECTOR
Credential: LPC
Phone: 864-457-4208