Provider Demographics
NPI:1245527001
Name:THE FIFTH SEASON CENTER FOR LOSS GRIEF AND TRANSITION
Entity type:Organization
Organization Name:THE FIFTH SEASON CENTER FOR LOSS GRIEF AND TRANSITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATTIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:BRODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:864-404-5070
Mailing Address - Street 1:111 MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4017
Mailing Address - Country:US
Mailing Address - Phone:864-241-8222
Mailing Address - Fax:864-241-8222
Practice Address - Street 1:111 MILLS AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4017
Practice Address - Country:US
Practice Address - Phone:864-241-8222
Practice Address - Fax:864-241-8222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-30
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5150101YP2500X
SC13051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty