Basic Information
| Provider Information | |||||||||
| NPI: | 1942943618 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEHAVIORS A GO-GO | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 219 GERALD DR | ||||||||
| Address2: | |||||||||
| City: | SIMPSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296814111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647579918 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3410 SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291693042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647579918 | ||||||||
| FaxNumber: | 8647579921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2022 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCORMICK | ||||||||
| AuthorizedOfficialFirstName: | ELIZA | ||||||||
| AuthorizedOfficialMiddleName: | KATHLEEN | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE & BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8649202527 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BEHAVIORS A GO-GO | ||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | GP7559 | 05 | SC | MEDICAID |