MEDICARE: HEALING ROOTS BEHAVIORAL HEALTH CENTER, LLC

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	1041C0700X	Clinical Social Worker	8883	SC

General Provider Information

NPI Number	:	1336697499
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALING ROOTS BEHAVIORAL HEALTH CENTER, LLC

Provider Business Mailing Address
First Line	:	200 W. 5TH NORTH STREET, SUITE C
Second Line	:	HEALING ROOTS BEHAVIORAL HEALTH CENTER, LLC
City	:	SUMMERVILLE
State	:	SC
Zip	:	29483-6618
Country	:	US
Telephone Number	:	843-695-8865
Fax Number	:	843-695-8517

Provider Business Practice Location Address
First Line	:	200 W. 5TH NORTH STREET, SUITE C
Second Line	:	HEALING ROOTS BEHAVIORAL HEALTH CENTER, LLC
City	:	SUMMERVILLE
State	:	SC
Zip	:	29483-6618
Country	:	US
Telephone Number	:	843-695-8865
Fax Number	:	843-695-8517

Authorized Official
Title or Position	:	THERAPIST/OWNER
Name	:	MRS. SHERIE R. CORBETT
Credential	:	MSW ,LISW-CP
Telephone Number	:	843-695-8865

Provider Enumeration Date	:	09/19/2016
Last Update Date	:	12/27/2017

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