Healthcare Provider Details

I. General information

NPI: 1427412162
Provider Name (Legal Business Name): MICHEAL G GORE MSSA, MSW, LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 BROAD ST
SUMTER SC
29150-4237
US

IV. Provider business mailing address

130 BROAD ST
SUMTER SC
29150-4237
US

V. Phone/Fax

Practice location:
  • Phone: 803-467-1263
  • Fax: 803-774-4378
Mailing address:
  • Phone: 803-467-1263
  • Fax: 803-774-4378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6773
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: