Basic Information
| Provider Information | |||||||||
| NPI: | 1093140352 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEM | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 STONY LANDING RD | ||||||||
| Address2: | |||||||||
| City: | MONCKS CORNER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294613967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437618282 | ||||||||
| FaxNumber: | 8437617308 | ||||||||
| Practice Location | |||||||||
| Address1: | 403 STONY LANDING RD | ||||||||
| Address2: | |||||||||
| City: | MONCKS CORNER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294613967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437618282 | ||||||||
| FaxNumber: | 8437617308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2013 | ||||||||
| LastUpdateDate: | 09/05/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 435201 | 05 | SC | MEDICAID |