Healthcare Provider Details

I. General information

NPI: 1205354917
Provider Name (Legal Business Name): ELEVATION COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 09/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110B HOSPITAL DR
SIMPSONVILLE SC
29681-3226
US

IV. Provider business mailing address

110B HOSPITAL DR
SIMPSONVILLE SC
29681-3226
US

V. Phone/Fax

Practice location:
  • Phone: 864-214-5492
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number5809
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK GOLDSMITH
Title or Position: SOLE PROPRIETOR
Credential: LPC
Phone: 864-214-5492