Provider Demographics
NPI:1790935336
Name:CENTER FOR PERSONAL GROWTH
Entity Type:Organization
Organization Name:CENTER FOR PERSONAL GROWTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:SOCIAL WORKER
Authorized Official - Phone:803-283-3810
Mailing Address - Street 1:150 B.W. THOMAS DRIVE
Mailing Address - Street 2:#125
Mailing Address - City:FT. MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708
Mailing Address - Country:US
Mailing Address - Phone:803-517-9816
Mailing Address - Fax:803-548-5343
Practice Address - Street 1:150 B W THOMAS DR
Practice Address - Street 2:#125
Practice Address - City:FT. MILL
Practice Address - State:SC
Practice Address - Zip Code:29708
Practice Address - Country:US
Practice Address - Phone:803-517-9816
Practice Address - Fax:803-548-5343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6244104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7810Medicare PIN