Provider Demographics
NPI:1245631167
Name:KERSHAW COUNTY SCHOOL DISTRICT
Entity type:Organization
Organization Name:KERSHAW COUNTY SCHOOL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR FOR INSTRUCTIONAL SUPPORT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:803-432-8416
Mailing Address - Street 1:2029 W DEKALB ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-2093
Mailing Address - Country:US
Mailing Address - Phone:803-432-8416
Mailing Address - Fax:803-425-8918
Practice Address - Street 1:1109 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-3507
Practice Address - Country:US
Practice Address - Phone:803-425-7712
Practice Address - Fax:803-425-7713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X, 103TC0700X, 1041S0200X, 101YS0200X
SC422103T00000X, 103TC1900X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2800Medicaid