MEDICARE: SAMUEL MITCHELL ELDER LISW-CP

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
2	104100000X	Social Worker	13054	SC

General Provider Information

NPI Number	:	1891356200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL MITCHELL ELDER LISW-CP

Provider Business Mailing Address
First Line	:	117 COMMONS WAY
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29611-3850
Country	:	US
Telephone Number	:	219-921-6988
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 HALTON RD STE J
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29607-3498
Country	:	US
Telephone Number	:	864-664-2710
Fax Number	:

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

Provider Enumeration Date	:	06/26/2019
Last Update Date	:	03/24/2022

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