Healthcare Provider Details

I. General information

NPI: 1578806642
Provider Name (Legal Business Name): TRACEY CAUGHMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 N RAMAGE ST
SALUDA SC
29138-1359
US

IV. Provider business mailing address

204 N RAMAGE ST
SALUDA SC
29138-1359
US

V. Phone/Fax

Practice location:
  • Phone: 864-445-2968
  • Fax: 864-445-9592
Mailing address:
  • Phone: 864-445-2968
  • Fax: 864-445-9592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4985
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: