Healthcare Provider Details

I. General information

NPI: 1043910706
Provider Name (Legal Business Name): AUSTIN TY CHRISTIAN MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 PALMETTO PARK BLVD
LEXINGTON SC
29072-7872
US

IV. Provider business mailing address

305 PALMETTO PARK BLVD
LEXINGTON SC
29072-7872
US

V. Phone/Fax

Practice location:
  • Phone: 803-996-1500
  • Fax:
Mailing address:
  • Phone: 803-996-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: