=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467665547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEMSON COUNSELING ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 214 KEOWEE TRL
-----------------------------------------------------
City | CLEMSON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29631-1448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-654-9263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 214 KEOWEE TRL
-----------------------------------------------------
City | CLEMSON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29631-1448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-654-9263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER PARTNER
-----------------------------------------------------
Name | DR. JUDSON STEWART MCKINNEY
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 864-654-9263
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 91
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------