Provider Demographics
NPI:1972845196
Name:SOUTH CAROLINA MENTOR
Entity Type:Organization
Organization Name:SOUTH CAROLINA MENTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL CONSULTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:843-513-0040
Mailing Address - Street 1:4 CARRIAGE LN
Mailing Address - Street 2:SUITE 302
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-6065
Mailing Address - Country:US
Mailing Address - Phone:843-573-1905
Mailing Address - Fax:843-573-1926
Practice Address - Street 1:4 CARRIAGE LN
Practice Address - Street 2:SUITE 302
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-6065
Practice Address - Country:US
Practice Address - Phone:843-573-1905
Practice Address - Fax:843-573-1926
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE MENTOR NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1-13-12976251S00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency