Basic Information
| Provider Information | |||||||||
| NPI: | 1194471052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BATES | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RONALD | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LPC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 910 COOK RD | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291182124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035342328 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 910 COOK RD | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291182124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035342328 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2022 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 7697 | SC | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 008533763 | 05 | SC | MEDICAID |