Provider Demographics
NPI:1588816870
Name:SANKOFA THERAPEUTIC CONCEPTS, LLC
Entity Type:Organization
Organization Name:SANKOFA THERAPEUTIC CONCEPTS, LLC
Other - Org Name:SANKOFA THERAPEUTIC CONCEPTS, PLLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/CLINICAL CONSULTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:DONITA
Authorized Official - Middle Name:P
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-CP
Authorized Official - Phone:803-207-0993
Mailing Address - Street 1:2879 HIGHWAY 160 W
Mailing Address - Street 2:PMB 4408
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-8581
Mailing Address - Country:US
Mailing Address - Phone:803-386-3064
Mailing Address - Fax:866-591-1741
Practice Address - Street 1:130 BEN CASEY DR
Practice Address - Street 2:STE 102
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-6567
Practice Address - Country:US
Practice Address - Phone:803-386-3064
Practice Address - Fax:866-591-1741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-17
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC87801041C0700X
NCC0054801041C0700X
NCF0704137363LP0808X
SC4345364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006793Medicaid