MEDICARE: KATHERINE HOPE BLACKLEY LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	8984	SC
2	101YM0800X	Mental Health Counselor	8984	SC
3	101YP2500X	Professional Counselor	8984	SC

General Provider Information

NPI Number	:	1073308441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE HOPE BLACKLEY LPC

Provider Business Mailing Address
First Line	:	2764 PLEASANT RD STE A413
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-7213
Country	:	US
Telephone Number	:	800-857-0709
Fax Number	:	803-560-0414

Provider Business Practice Location Address
First Line	:	2764 PLEASANT RD STE A413
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-7213
Country	:	US
Telephone Number	:	800-857-0709
Fax Number	:	803-560-0414

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2025
Last Update Date	:	04/14/2025

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