1619212917 NPI number — DEPARTMENT OF JUVENILE JUSTICE

Table of content: (NPI 1619212917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619212917 NPI number — DEPARTMENT OF JUVENILE JUSTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEPARTMENT OF JUVENILE JUSTICE
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:
Provider Other Organization Name Type Code:
6
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:
1619212917
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 BRADFORD KNOLL CT
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:
29223-7142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-788-8911
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1725 SHIVERS RD
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:
29210-5413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-896-5695
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BENNETT-YORK
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
Authorized Official Title or Position:
SOCIAL WORKER
Authorized Official Telephone Number:
803-788-8911

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  4663 , 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)

  • Identifier: 29832 . This is a "AMERICAN BOARD OF EXAMINERS OF CLINICAL SOCIAL WORKERS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 4663 . This is a "LICENSED BY THE BOARD OF SOCIAL WORK EXAMINERS" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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