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General NPI Number Information
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NPI Number | 1750308409
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Entity Type | Organization
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Legal Business Name | DUTCH FORK PSYCHOLOGICAL SERVICES
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Dates
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Enumeration Date | 07/17/2006
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Last Update Date | 04/27/2015
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Provider Practice Location Address
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Address Line | 7313 COLLEGE ST
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City | IRMO
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State | SC
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Zip | 29063-2902
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Country | US
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Telephone | 803-407-7099
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Fax | 803-807-9104
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Provider Business Mailing Address
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Address Line | 7313 COLLEGE ST
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City | IRMO
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State | SC
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Zip | 29063-2902
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Country | US
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Telephone | 803-407-7099
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Fax | 803-807-9104
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Authorized Official
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Title or Position | OWNER
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Name | DR. WILLIAM E. HAXTON
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Credential | PH.D.
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Telephone | 803-407-7099
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 654
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License Number State | SC
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