Provider Demographics
NPI:1417341611
Name:FULLCIRCLE COUNSELING SERVICE AND CONSULTATION
Entity Type:Organization
Organization Name:FULLCIRCLE COUNSELING SERVICE AND CONSULTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:803-467-4125
Mailing Address - Street 1:105 PACES BROOK AVE
Mailing Address - Street 2:#518
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-1642
Mailing Address - Country:US
Mailing Address - Phone:803-467-4125
Mailing Address - Fax:803-569-6523
Practice Address - Street 1:105 PACES BROOK AVE
Practice Address - Street 2:#518
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1642
Practice Address - Country:US
Practice Address - Phone:803-467-4125
Practice Address - Fax:803-569-6523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4911101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC1102Medicaid