=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952838328
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BERKELEY COUNTY SCHOOL DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2017
-----------------------------------------------------
Last Update Date | 05/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1624 STATE RD
-----------------------------------------------------
City | SUMMERVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29486-2752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-899-8786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 E MAIN ST POST OFFICE BOX 608
-----------------------------------------------------
City | MONCKS CORNER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29461-3764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | KELLY WULF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-899-8890
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225CX0006X
-----------------------------------------------------
Taxonomy Name | Orientation and Mobility Training Rehabilitation Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------