Healthcare Provider Details

I. General information

NPI: 1427606409
Provider Name (Legal Business Name): PLAY THERAPY OF SUMTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 N MAIN ST
SUMTER SC
29150-4958
US

IV. Provider business mailing address

121 N PURDY ST
SUMTER SC
29150-4524
US

V. Phone/Fax

Practice location:
  • Phone: 803-983-6735
  • Fax:
Mailing address:
  • Phone: 803-968-5999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CATHERINE L GIBSON
Title or Position: OWNER
Credential: LPC
Phone: 803-983-6735