MEDICARE: SC PROFESSIONAL SERVICES, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363LP2300X	Primary Care Nurse Practitioner
2	207Q00000X	Family Medicine Physician
3	101YA0400X	Addiction (Substance Use Disorder) Counselor
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
5	2084P0800X	Psychiatry Physician
6	207RA0401X	Addiction Medicine (Internal Medicine) Physician
7	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1447078233
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SC PROFESSIONAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	1064 GARDNER RD STE 215
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-1712
Country	:	US
Telephone Number	:	843-779-7718
Fax Number	:	404-920-3484

Provider Business Practice Location Address
First Line	:	1064 GARDNER RD STE 215
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-1712
Country	:	US
Telephone Number	:	843-779-7718
Fax Number	:	404-920-3484

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MS. KASSI GOODMAN
Credential	:	LPC
Telephone Number	:	843-779-7718

Provider Enumeration Date	:	09/30/2024
Last Update Date	:	01/13/2026

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