1770817462 NPI number — MS. GAYLE R POLSTON MA, LPC, NCC

Table of content: MS. GAYLE R POLSTON MA, LPC, NCC (NPI 1770817462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770817462 NPI number — MS. GAYLE R POLSTON MA, LPC, NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLSTON
Provider First Name:
GAYLE
Provider Middle Name:
R
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC, NCC
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:
1770817462
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
704 S FRANKLIN DR
Provider Second Line Business Mailing Address:
LIFE CHANGING SOLUTIONS
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29501-4504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-669-4233
Provider Business Mailing Address Fax Number:
843-472-5021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1807 CHEROKEE RD STE 202
Provider Second Line Business Practice Location Address:
LIFE CHANGING SOLUTIONS, LLC
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29501-3101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-669-4233
Provider Business Practice Location Address Fax Number:
843-472-5021
Provider Enumeration Date:
09/28/2009

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: 101YP2500X , with the licence number:  5064 , 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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