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General NPI Number Information
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NPI Number | 1972265502
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Entity Type | Organization
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Legal Business Name | UPSTATE ADHD CENTER, LLC
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Dates
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Enumeration Date | 10/11/2021
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Last Update Date | 10/11/2023
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Provider Practice Location Address
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Address Line | 300 JOHN ST UNIT 5B
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City | GREER
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State | SC
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Zip | 29651-1463
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Country | US
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Telephone | 864-714-5637
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 25472
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City | GREENVILLE
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State | SC
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Zip | 29616-0472
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Country | US
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Telephone | 864-714-5637
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | WANDA SAMAKE
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Credential | DNP, PMHNP-BC, APRN
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Telephone | 864-714-5637
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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