1235614751 NPI number — WILLOW OAK COUNSELING AND BEHAVIORAL SERVICES, LLC.

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 1235614751 NPI number — WILLOW OAK COUNSELING AND BEHAVIORAL SERVICES, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLOW OAK COUNSELING AND BEHAVIORAL SERVICES, LLC.
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:
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:
1235614751
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14323 OCEAN HWY UNIT 4103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAWLEYS ISLAND
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29585-4817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-314-0416
Provider Business Mailing Address Fax Number:
866-580-4842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14323 OCEAN HWY UNIT 4103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAWLEYS ISLAND
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29585-4817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-779-2264
Provider Business Practice Location Address Fax Number:
866-580-4842
Provider Enumeration Date:
10/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
ROMAN
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
OWNER/LICENSED PROFESSIONAL COUNSEL
Authorized Official Telephone Number:
843-779-2264

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: W80629SC1 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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