=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598072282
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALMETTO LOWCOUNTRY BEHAVIORAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2010
-----------------------------------------------------
Last Update Date | 09/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2777 SPEISSEGGER DR.
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29405-8235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-747-5830
-----------------------------------------------------
Fax | 843-745-5115
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2777 SPEISSEGGER DR.
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29405-8235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-747-5830
-----------------------------------------------------
Fax | 843-745-5115
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | CHERIE TOLLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-747-5830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------