Provider Demographics
NPI:1215408711
Name:CULBERTSON, MITCHELL (MBA, MS, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:CULBERTSON
Suffix:
Gender:M
Credentials:MBA, MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 BOWHUNTER DR
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-9204
Mailing Address - Country:US
Mailing Address - Phone:803-754-3892
Mailing Address - Fax:
Practice Address - Street 1:3031 SCOTSMAN RD STE 20
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-1812
Practice Address - Country:US
Practice Address - Phone:803-834-8272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-09
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7655101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional