Provider Demographics
NPI:1295032878
Name:S.C.DEPT OF MENTAL HEALTH
Entity Type:Organization
Organization Name:S.C.DEPT OF MENTAL HEALTH
Other - Org Name:PEE DEE MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HUMAN SERVICE SPECIALST
Authorized Official - Prefix:MS
Authorized Official - First Name:ZONDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-431-1100
Mailing Address - Street 1:125 E CHEVES ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2526
Mailing Address - Country:US
Mailing Address - Phone:843-317-4089
Mailing Address - Fax:843-317-4096
Practice Address - Street 1:125 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2526
Practice Address - Country:US
Practice Address - Phone:843-317-4089
Practice Address - Fax:843-317-4096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3337OtherMEDICARE
SC376241Medicaid