Provider Demographics
NPI:1619212917
Name:DEPARTMENT OF JUVENILE JUSTICE
Entity Type:Organization
Organization Name:DEPARTMENT OF JUVENILE JUSTICE
Other - Org Name:SOUTH CAROLINA STATE GOVERNMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT-YORK
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-CP, BCD
Authorized Official - Phone:803-788-8911
Mailing Address - Street 1:11 BRADFORD KNOLL CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-7142
Mailing Address - Country:US
Mailing Address - Phone:803-788-8911
Mailing Address - Fax:
Practice Address - Street 1:1725 SHIVERS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-5413
Practice Address - Country:US
Practice Address - Phone:806-896-5695
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-28
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4663251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC29832OtherAMERICAN BOARD OF EXAMINERS OF CLINICAL SOCIAL WORKERS
SC4663OtherLICENSED BY THE BOARD OF SOCIAL WORK EXAMINERS