Healthcare Provider Details

I. General information

NPI: 1053847285
Provider Name (Legal Business Name): CHESTNUT HILL MENTAL HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2017
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HAVENWOOD LN
TRAVELERS REST SC
29690-9447
US

IV. Provider business mailing address

1 HAVENWOOD LN
TRAVELERS REST SC
29690-9447
US

V. Phone/Fax

Practice location:
  • Phone: 864-834-8013
  • Fax:
Mailing address:
  • Phone: 864-834-8013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateSC
# 7
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateSC
# 8
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateSC

VIII. Authorized Official

Name: DAVID B BURLESON
Title or Position: DIRECTOR OF BUSINESS DEVELOPMENT
Credential:
Phone: 864-834-8013