Basic Information
| Provider Information | |||||||||
| NPI: | 1801998539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TATE | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 124 MALLARD STREET | ||||||||
| Address2: | GMHC | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296014046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642411040 | ||||||||
| FaxNumber: | 8642411016 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 MALLARD STREET | ||||||||
| Address2: | GMHC | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296014046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642411040 | ||||||||
| FaxNumber: | 8642411016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3586 | SC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 301100 | 05 | SC | MEDICAID |