Provider Demographics
NPI:1639415920
Name:INDIVIDUAL
Entity type:Organization
Organization Name:INDIVIDUAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SOCIAL WORK
Authorized Official - Prefix:MS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:803-896-4813
Mailing Address - Street 1:1725 SHIVERS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-5413
Mailing Address - Country:US
Mailing Address - Phone:803-896-5732
Mailing Address - Fax:803-896-5723
Practice Address - Street 1:1725 SHIVERS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-5413
Practice Address - Country:US
Practice Address - Phone:803-896-5732
Practice Address - Fax:803-896-5723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5322322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children