=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376976837
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEED HARVEST TIME RESIDENTIAL BEHAVIORAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2013
-----------------------------------------------------
Last Update Date | 08/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 209 HAMPTON AVE
-----------------------------------------------------
City | KINGSTREE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29556-3415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-401-0005
-----------------------------------------------------
Fax | 843-401-0006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 444 MANNING HWY
-----------------------------------------------------
City | GREELEYVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29056-9299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-319-7843
-----------------------------------------------------
Fax | 843-401-0006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | ROSALIND GAMBLE
-----------------------------------------------------
Credential | M.A.,PMHC
-----------------------------------------------------
Telephone | 843-319-7843
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------