Provider Demographics
NPI:1922583277
Name:PROFESSIONAL ADDICTION SERVICES LLC
Entity Type:Organization
Organization Name:PROFESSIONAL ADDICTION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:254-760-9603
Mailing Address - Street 1:306 BRICK KILN DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-5415
Mailing Address - Country:US
Mailing Address - Phone:254-760-9603
Mailing Address - Fax:
Practice Address - Street 1:133 E 1ST NORTH ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6873
Practice Address - Country:US
Practice Address - Phone:254-760-9610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-02
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health