Provider Demographics
NPI:1750308409
Name:DUTCH FORK PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:DUTCH FORK PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:HAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:803-407-7099
Mailing Address - Street 1:7313 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2902
Mailing Address - Country:US
Mailing Address - Phone:803-407-7099
Mailing Address - Fax:803-807-9104
Practice Address - Street 1:7313 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2902
Practice Address - Country:US
Practice Address - Phone:803-407-7099
Practice Address - Fax:803-807-9104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC654103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4164Medicaid