Healthcare Provider Details

I. General information

NPI: 1124764568
Provider Name (Legal Business Name): WILLIAM J. MCCORD ADOLESCENT TREATMENT FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 COOK RD
ORANGEBURG SC
29118-2124
US

IV. Provider business mailing address

416 MEADOWLAKE DR
COLUMBIA SC
29203-2418
US

V. Phone/Fax

Practice location:
  • Phone: 803-534-2328
  • Fax:
Mailing address:
  • Phone: 803-606-9783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
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: MIKE DENNIS
Title or Position: DIRECTOR
Credential:
Phone: 803-534-2328