Healthcare Provider Details

I. General information

NPI: 1114918372
Provider Name (Legal Business Name): JAY WILLIAM KNOTTS MED LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 GEORGIA AVE CENTER FOR CARE AND COUNSELING FOR THE CSRA INC
NORTH AUGUSTA SC
29841-3703
US

IV. Provider business mailing address

625 GEORGIA AVE CENTER FOR CARE AND COUNSELING FOR THE CSRA INC
NORTH AUGUSTA SC
29841-3703
US

V. Phone/Fax

Practice location:
  • Phone: 803-819-8021
  • Fax: 803-819-9028
Mailing address:
  • Phone: 803-819-8021
  • Fax: 803-819-9028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4115
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: