Healthcare Provider Details

I. General information

NPI: 1255101598
Provider Name (Legal Business Name): MIDLANDS WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 BROAD ST STE 101
SUMTER SC
29150-3368
US

IV. Provider business mailing address

25 KILLARNEY LN
SUMTER SC
29150-7050
US

V. Phone/Fax

Practice location:
  • Phone: 803-720-9151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE ROBERTS
Title or Position: OWNER
Credential: LISW-CP
Phone: 803-720-9151