Healthcare Provider Details

I. General information

NPI: 1124512132
Provider Name (Legal Business Name): CHOICES COUNSELING AND ADVOCACY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 06/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3969 SOUTHEASTERN WAY
WEST COLUMBIA SC
29169
US

IV. Provider business mailing address

3969 SOUTHEASTERN WAY
WEST COLUMBIA SC
29169-2442
US

V. Phone/Fax

Practice location:
  • Phone: 803-851-4049
  • Fax:
Mailing address:
  • Phone: 803-851-4049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5155
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number5155
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number5155
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number5155
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number5155
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number5155
License Number StateSC

VIII. Authorized Official

Name: MRS. CHRISTINE JOHNSON
Title or Position: CLINICAL DIRECTOR
Credential: LPC
Phone: 803-851-4049