Provider Demographics
NPI:1457168163
Name:KINTSUGI BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:KINTSUGI BEHAVIORAL HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAI
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-CP
Authorized Official - Phone:843-410-9940
Mailing Address - Street 1:3301 SALTERBECK ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7165
Mailing Address - Country:US
Mailing Address - Phone:843-410-9940
Mailing Address - Fax:
Practice Address - Street 1:3301 SALTERBECK ST STE 101
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7165
Practice Address - Country:US
Practice Address - Phone:843-410-9940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-16
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health