Provider Demographics
NPI:1558499426
Name:PSYCHIATRIC ASSOCIATES OF SPARTANBURG, PA
Entity Type:Organization
Organization Name:PSYCHIATRIC ASSOCIATES OF SPARTANBURG, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-585-2214
Mailing Address - Street 1:943 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-2712
Mailing Address - Country:US
Mailing Address - Phone:864-585-2214
Mailing Address - Fax:864-585-5608
Practice Address - Street 1:943 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-2712
Practice Address - Country:US
Practice Address - Phone:864-585-2214
Practice Address - Fax:864-585-5608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2064101YP2500X
SC1304106H00000X
SC068712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC068713Medicaid
SCC60700Medicare UPIN