Healthcare Provider Details

I. General information

NPI: 1336942853
Provider Name (Legal Business Name): THRIVE WELLNESS AND PERFORMANCE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 03/31/2025
Certification Date: 03/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 BRYCE CIR STE C
SIMPSONVILLE SC
29681-4842
US

IV. Provider business mailing address

205 BRYCE CIR STE C
SIMPSONVILLE SC
29681-4842
US

V. Phone/Fax

Practice location:
  • Phone: 864-420-3605
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JAY WILES
Title or Position: PSYCHOLOGIST AND OWNER
Credential: PSY.D.
Phone: 864-420-3605