Healthcare Provider Details

I. General information

NPI: 1063275972
Provider Name (Legal Business Name): MISS EBONY LPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 HERIOT ST
MANNING SC
29102
US

IV. Provider business mailing address

652 BUSH RIVER RD STE 217
COLUMBIA SC
29210-7537
US

V. Phone/Fax

Practice location:
  • Phone: 803-339-2221
  • Fax:
Mailing address:
  • Phone: 803-339-2221
  • Fax:

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: EBONY LANGHORNE
Title or Position: OWNER
Credential:
Phone: 803-339-2221