Healthcare Provider Details

I. General information

NPI: 1699406363
Provider Name (Legal Business Name): PERSONAL HEALING AND MENTORING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8887 OLD UNIVERSITY BLVD
NORTH CHARLESTON SC
29406-7123
US

IV. Provider business mailing address

109 HICKORY RIDGE WAY
SUMMERVILLE SC
29483-9759
US

V. Phone/Fax

Practice location:
  • Phone: 843-619-8872
  • 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 Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. TRAVIS THOMPSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 843-619-8872