1801992995 NPI number — LARUE J BETTIS M.ED, LPCS

Table of content: LARUE J BETTIS M.ED, LPCS (NPI 1801992995)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801992995 NPI number — LARUE J BETTIS M.ED, LPCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BETTIS
Provider First Name:
LARUE
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.ED, LPCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1801992995
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130A WHITEFORD WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29072-7617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-808-1800
Provider Business Mailing Address Fax Number:
803-356-8580

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130A WHITEFORD WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29072-7617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-808-1800
Provider Business Practice Location Address Fax Number:
803-356-8580
Provider Enumeration Date:
09/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  2148 , 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)