Provider Demographics
NPI:1528417128
Name:BACON, CONSTANCE
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 ATRIUM WAY STE 110
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6382
Mailing Address - Country:US
Mailing Address - Phone:803-791-7328
Mailing Address - Fax:803-791-4198
Practice Address - Street 1:115 ATRIUM WAY STE 110
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6382
Practice Address - Country:US
Practice Address - Phone:803-791-7328
Practice Address - Fax:803-791-4198
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC421504Medicaid
SC3335Medicare PIN
SC421504Medicare PIN