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General NPI Number Information
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NPI Number | 1639415920
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Entity Type | Organization
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Legal Business Name | INDIVIDUAL
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Dates
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Enumeration Date | 12/14/2012
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Last Update Date | 12/14/2012
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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 | 803-896-5732
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Fax | 803-896-5723
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Provider Business Mailing 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 | 803-896-5732
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Fax | 803-896-5723
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Authorized Official
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Title or Position | DIRECTOR OF SOCIAL WORK
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Name | MS. JAN GIESEN
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Credential | LISW
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Telephone | 803-896-4813
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 5322
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License Number State | SC
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