MEDICARE: BEHAVIORAL DIAGNOSTICS, 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	103TC0700X	Clinical Psychologist	447	SC

Other Identifiers

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

General Provider Information

NPI Number	:	1992063275
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEHAVIORAL DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1481
Second Line	:
City	:	HOLLY HILL
State	:	SC
Zip	:	29059-1481
Country	:	US
Telephone Number	:	843-509-6819
Fax Number	:	803-496-7237

Provider Business Practice Location Address
First Line	:	108 STAGECOACH LN
Second Line	:
City	:	ORANGEBURG
State	:	SC
Zip	:	29118-2499
Country	:	US
Telephone Number	:	843-509-6819
Fax Number	:	803-496-7237

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	DR. JAMES HOWARD WAY
Credential	:	PH.D.
Telephone Number	:	843-509-6819

Provider Enumeration Date	:	04/24/2012
Last Update Date	:	04/24/2012

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