Healthcare Provider Details

I. General information

NPI: 1396344230
Provider Name (Legal Business Name): TAMIKA T STEVENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 ARNOLD MILL RD
SIMPSONVILLE SC
29680-7293
US

IV. Provider business mailing address

133 ARNOLD MILL RD
SIMPSONVILLE SC
29680-7293
US

V. Phone/Fax

Practice location:
  • Phone: 267-671-2311
  • Fax:
Mailing address:
  • Phone: 267-671-2311
  • Fax: 864-412-7989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: