Basic Information
| Provider Information | |||||||||
| NPI: | 1124764568 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLIAM J. MCCORD ADOLESCENT TREATMENT FACILITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 416 MEADOWLAKE DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292032418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8036069783 | ||||||||
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| Practice Location | |||||||||
| Address1: | 910 COOK RD | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291182124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035342328 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2022 | ||||||||
| LastUpdateDate: | 05/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | DENNIS | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8035342328 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 101Y00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
No ID Information.