=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578126181
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEASON 4 CHANGE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2019
-----------------------------------------------------
Last Update Date | 12/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3524 JEFFERSON DAVIS HWY
-----------------------------------------------------
City | GRANITEVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29829-9998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-380-9004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 139 BARNARD AVE SE
-----------------------------------------------------
City | AIKEN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29801-7203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-508-2582
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | MR. DARRELL WILLIAM JONES
-----------------------------------------------------
Credential | LISW-CP
-----------------------------------------------------
Telephone | 912-508-2582
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------