Provider Demographics
NPI: | 1639415920 |
---|---|
Name: | INDIVIDUAL |
Entity Type: | Organization |
Organization Name: | INDIVIDUAL |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DIRECTOR OF SOCIAL WORK |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | JAN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GIESEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LISW |
Authorized Official - Phone: | 803-896-4813 |
Mailing Address - Street 1: | 1725 SHIVERS RD |
Mailing Address - Street 2: | |
Mailing Address - City: | COLUMBIA |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29210-5413 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 803-896-5732 |
Mailing Address - Fax: | 803-896-5723 |
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: | 803-896-5732 |
Practice Address - Fax: | 803-896-5723 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-12-14 |
Last Update Date: | 2012-12-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SC | 5322 | 322D00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 322D00000X | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |