Healthcare Provider Details

I. General information

NPI: 1114812674
Provider Name (Legal Business Name): FRESH START MENTAL HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2025
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6223 CHADDERTON CIRCLE
MYRTLE BEACH SC
29579-4484
US

IV. Provider business mailing address

6223 CHADDERTON CIRCLE
MYRTLE BEACH SC
29579-4484
US

V. Phone/Fax

Practice location:
  • Phone: 301-213-1306
  • Fax:
Mailing address:
  • Phone: 301-213-1306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KIMBERLY DAVIS
Title or Position: CREDENTIALING SPECIALISTS
Credential:
Phone: 912-373-4385