Healthcare Provider Details

I. General information

NPI: 1750406476
Provider Name (Legal Business Name): ERNEST E. KENNEDY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 AIRPORT DR
MONCKS CORNER SC
29461-2629
US

IV. Provider business mailing address

306 AIRPORT DR
MONCKS CORNER SC
29461-2629
US

V. Phone/Fax

Practice location:
  • Phone: 843-719-3000
  • Fax: 843-719-3025
Mailing address:
  • Phone: 843-719-3000
  • Fax: 843-719-3025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3396
License Number StateSC

VIII. Authorized Official

Name: MR. JEROME TILGHMAN JR.
Title or Position: DIRECTOR OF CLINICAL SERVICES
Credential: LPC
Phone: 843-719-3000