MEDICARE: STEPHEN GUNSALLUS LPCI

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	101YM0800X	Mental Health Counselor	4748	SC

General Provider Information

NPI Number	:	1205046588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN GUNSALLUS LPCI

Provider Business Mailing Address
First Line	:	20 STARBOARD TACK DR
Second Line	:
City	:	SALEM
State	:	SC
Zip	:	29676-4026
Country	:	US
Telephone Number	:	864-944-7074
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 STARBOARD TACK DR
Second Line	:
City	:	SALEM
State	:	SC
Zip	:	29676-4026
Country	:	US
Telephone Number	:	864-944-7074
Fax Number	:

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/08/2007

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