Provider Demographics
NPI:1114322625
Name:ELIZABETH CORBETT, LLC
Entity Type:Organization
Organization Name:ELIZABETH CORBETT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CORBETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:803-361-7940
Mailing Address - Street 1:105 LAZY ACRES DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-4255
Mailing Address - Country:US
Mailing Address - Phone:803-361-7940
Mailing Address - Fax:803-695-4934
Practice Address - Street 1:1612 MARION ST
Practice Address - Street 2:SUITE 311
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2939
Practice Address - Country:US
Practice Address - Phone:803-361-7940
Practice Address - Fax:803-695-4935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4991251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1153Medicaid