Healthcare Provider Details

I. General information

NPI: 1417601980
Provider Name (Legal Business Name): SACRED GROVE COUNSELING & HEALING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 02/06/2022
Certification Date: 02/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 N CHURCH ST
LEXINGTON SC
29072-2808
US

IV. Provider business mailing address

114 N CHURCH ST
LEXINGTON SC
29072-2808
US

V. Phone/Fax

Practice location:
  • Phone: 803-210-7422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. WENNDY DUPKOSKI
Title or Position: COUNSELOR
Credential: PHD, LPC-S, LPC, NCC
Phone: 803-210-7422