Provider Demographics
NPI:1083144125
Name:RADICAL TRANSFORMATIONS COUNSELING SERVICES LLC
Entity Type:Organization
Organization Name:RADICAL TRANSFORMATIONS COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINCIAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:DEANA
Authorized Official - Middle Name:LENETTE
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MA,CACII, LPC,MAC
Authorized Official - Phone:803-727-0658
Mailing Address - Street 1:PO BOX 8781
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-8781
Mailing Address - Country:US
Mailing Address - Phone:803-727-0658
Mailing Address - Fax:
Practice Address - Street 1:630 OLD ORANGEBURG RD APT A
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29073-6927
Practice Address - Country:US
Practice Address - Phone:803-727-0658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-12
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6111251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC1559Medicaid