Provider Demographics
NPI:1538973219
Name:PASCAVAGE, MATTHEW DOMINIC
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DOMINIC
Last Name:PASCAVAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2113 GREENWYCHE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-6232
Mailing Address - Country:US
Mailing Address - Phone:336-905-1253
Mailing Address - Fax:
Practice Address - Street 1:1500 LADY ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3402
Practice Address - Country:US
Practice Address - Phone:803-766-2188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-04
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9130101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health