Provider Demographics
NPI:1902403116
Name:PIECES 2 PEACE WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:PIECES 2 PEACE WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:B
Authorized Official - Last Name:GANTT-GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:803-250-5198
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29290-0054
Mailing Address - Country:US
Mailing Address - Phone:803-250-5198
Mailing Address - Fax:
Practice Address - Street 1:1105 BELLEVIEW ST STE 103
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-1839
Practice Address - Country:US
Practice Address - Phone:803-250-5198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC2197Medicaid
SCQMP000005514755OtherMOLINA HEALTHCARE