=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225243835
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOUGLAS FOTIA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9326 MEDICAL PLAZA DR STE A
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-9138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-377-1600
-----------------------------------------------------
Fax | 843-377-1601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9326 MEDICAL PLAZA DR STE A
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-9138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-377-1600
-----------------------------------------------------
Fax | 843-377-1601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DOUGLAS FOTIA
-----------------------------------------------------
Credential | LISW-CP
-----------------------------------------------------
Telephone | 843-412-3300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6167
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------