1255390001 NPI number — NORTHEAST COLUMBIA PSYCHOTHERAPY PRACTICE INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255390001 NPI number — NORTHEAST COLUMBIA PSYCHOTHERAPY PRACTICE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST COLUMBIA PSYCHOTHERAPY PRACTICE INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NORHEAST COLUMBIA PSYCHOTHERAPY PRACTICE, INC
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255390001
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 POACHERS LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29223-3014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-736-7133
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9 POACHERS LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29223-3014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-736-7133
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARIS
Authorized Official First Name:
BETH
Authorized Official Middle Name:
TROY
Authorized Official Title or Position:
THERAPIST/PRESIDENT
Authorized Official Telephone Number:
803-736-7133

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LISW-CP 134 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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