Provider Demographics
NPI:1265441265
Name:FURTICK, JAMES JR (PHD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:FURTICK
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:JIM
Other - Middle Name:
Other - Last Name:FURTICK
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:108 STAGE COACH LANE
Mailing Address - Street 2:VILLAGE PARK
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2499
Mailing Address - Country:US
Mailing Address - Phone:803-516-0200
Mailing Address - Fax:803-516-8288
Practice Address - Street 1:108 STAGE COACH LANE
Practice Address - Street 2:VILLAGE PARK
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2499
Practice Address - Country:US
Practice Address - Phone:803-516-0200
Practice Address - Fax:803-516-8288
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4068101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1049Medicaid