MEDICARE: REDISCOVERY, 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1992276778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REDISCOVERY, LLC

Provider Business Mailing Address
First Line	:	253 HART ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29203-5417
Country	:	US
Telephone Number	:	843-338-5205
Fax Number	:	803-753-0115

Provider Business Practice Location Address
First Line	:	253 HART ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29203-5417
Country	:	US
Telephone Number	:	843-338-5205
Fax Number	:	803-753-0115

Authorized Official
Title or Position	:	OWNER
Name	:	MISS LEANNA IRY GORDON
Credential	:	LMSW
Telephone Number	:	843-338-5205

Provider Enumeration Date	:	12/05/2018
Last Update Date	:	12/05/2018

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