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General NPI Number Information
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NPI Number | 1619212917
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Entity Type | Organization
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Legal Business Name | DEPARTMENT OF JUVENILE JUSTICE
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Dates
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Enumeration Date | 11/28/2012
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Last Update Date | 12/03/2012
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Provider Practice Location Address
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Address Line | 1725 SHIVERS RD
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City | COLUMBIA
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State | SC
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Zip | 29210-5413
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Country | US
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Telephone | 806-896-5695
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Fax |
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Provider Business Mailing Address
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Address Line | 11 BRADFORD KNOLL CT
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City | COLUMBIA
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State | SC
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Zip | 29223-7142
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Country | US
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Telephone | 803-788-8911
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Fax |
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Authorized Official
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Title or Position | SOCIAL WORKER
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Name | MS. DEBORAH BENNETT-YORK
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Credential | LISW-CP, BCD
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Telephone | 803-788-8911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 4663
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License Number State | SC
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