=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407326135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SWEETGRASS COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2018
-----------------------------------------------------
Last Update Date | 11/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302A MIDLAND PKWY
-----------------------------------------------------
City | SUMMERVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29485-8102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-259-6535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3590 MARY ADER AVE APT 1021
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29414-5792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-712-0026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMY F JACKSON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 843-259-6535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------