MEDICARE: A SOUND MIND

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	101YP2500X	Professional Counselor	2590	SC
2	1041C0700X	Clinical Social Worker	4379	SC

General Provider Information

NPI Number	:	1689812216
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A SOUND MIND

Provider Business Mailing Address
First Line	:	1315 W MARTINTOWN RD
Second Line	:
City	:	NORTH AUGUSTA
State	:	SC
Zip	:	29860-7631
Country	:	US
Telephone Number	:	803-442-9410
Fax Number	:	803-426-1574

Provider Business Practice Location Address
First Line	:	1315 W MARTINTOWN RD
Second Line	:
City	:	NORTH AUGUSTA
State	:	SC
Zip	:	29860-7631
Country	:	US
Telephone Number	:	803-442-9410
Fax Number	:	803-426-1574

Authorized Official
Title or Position	:	THERAPIST
Name	:	MR. THOMAS JOSEPH PORTNEY
Credential	:	LISW-CP
Telephone Number	:	803-442-9410

Provider Enumeration Date	:	02/04/2009
Last Update Date	:	02/04/2009

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Directions to “A SOUND MIND ” Practice Location

Language	Start Address	Practice Location

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