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NPI Code Detail

MEDICARE: MIND RENEWAL SERVICES, LLC

MEDICARE: MIND RENEWAL SERVICES, 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
11041C0700XClinical Social Worker10538SC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1447679519
Entity Type Code : Organization
Provider Name (Legal Business Name) : MIND RENEWAL SERVICES, LLC
Provider Business Mailing Address
First Line : 439 CONGAREE RD
Second Line :
City : GREENVILLE
State : SC
Zip : 29607-2867
Country : US
Telephone Number : 864-509-9087
Fax Number : 864-509-9072
Provider Business Practice Location Address
First Line : 439 CONGAREE RD
Second Line :
City : GREENVILLE
State : SC
Zip : 29607-2867
Country : US
Telephone Number : 864-509-9087
Fax Number : 864-509-9072
Authorized Official
Title or Position : CLINICAL SOCIAL WORKER
Name : MRS. BRANDY THOMPSON-FISHER
Credential : LISW-CP
Telephone Number : 443-867-6663
Provider Enumeration Date : 04/15/2014
Last Update Date : 04/15/2014

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