Provider Demographics
NPI:1184765653
Name:PROFESSIONAL INTENSIVE OUTPATIENT PROGRAM OF FLORENCE
Entity type:Organization
Organization Name:PROFESSIONAL INTENSIVE OUTPATIENT PROGRAM OF FLORENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC, LPCS
Authorized Official - Phone:843-673-0054
Mailing Address - Street 1:323 S MCQUEEN ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4722
Mailing Address - Country:US
Mailing Address - Phone:843-673-0054
Mailing Address - Fax:843-667-1549
Practice Address - Street 1:323 S MCQUEEN ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4722
Practice Address - Country:US
Practice Address - Phone:843-673-0054
Practice Address - Fax:843-667-1549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC326101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty