Healthcare Provider Details

I. General information

NPI: 1336508878
Provider Name (Legal Business Name): FAYONA DIANA JAMES CURENTON LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FAYONA DIANA JAMES LISW

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 07/12/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S CHURCH ST STE 14
SPARTANBURG SC
29306-3306
US

IV. Provider business mailing address

PO BOX 740013
ATLANTA GA
30374-0013
US

V. Phone/Fax

Practice location:
  • Phone: 864-774-7001
  • Fax:
Mailing address:
  • Phone: 773-644-3941
  • Fax: 614-685-3081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number151229
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI.1101015
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI 1101015.SUPV
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16767
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: