Provider Demographics
NPI:1679009559
Name:PLAY THERAPY WITH CARMEN
Entity Type:Organization
Organization Name:PLAY THERAPY WITH CARMEN
Other - Org Name:CARMEN JIMENEZ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LISW, LCSW, RPTS
Authorized Official - Phone:980-275-2505
Mailing Address - Street 1:PO BOX 8804
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-8804
Mailing Address - Country:US
Mailing Address - Phone:980-275-2505
Mailing Address - Fax:
Practice Address - Street 1:300 BERKSHIRE DR STE F
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-1859
Practice Address - Country:US
Practice Address - Phone:980-275-2505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUTSPOKEN COUNSELING AND CONSULTING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC104781041C0700X
SCC0085051041C0700X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty