Excalibur Youth Services, LLC.

Primary specialty

Psychiatric Residential Treatment FacilityTaxonomy code 323P00000X

License

RTF-0022 Issued in SC

Legal business name

EXCALIBUR YOUTH SERVICES, LLC.

Doing business as

Broadstep Academy-SC Inc
Venice Psychiatric Residential Treatment Facility

Practice address

3683 S. Industrial Dr.
Simpsonville, SC 29681

Phone

(864) 688-1133

Fax

(864) 962-6976

NPI assigned

Jan 21, 2009

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Isabelle Williams

Title

Manager, Revenue Cycle

Phone

(919) 703-2829

Specialties & licenses 2

Addresses

Other identifiers 2

Other names 2

• Broadstep Academy-SC Inc Doing business as
• Venice Psychiatric Residential Treatment Facility Doing business as

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Psychiatric residential treatment facility certification: CCN 42L014

Legal name

VENICE PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY

Certification status

Active

Provider type (POS)

Psychiatric residential treatment facility

Participating since

Jul 11, 2012

Last certification

Aug 28, 2025

Beds

60

Ownership / control type

For profit – partnership

Facility address

3683 South Industrial Dr
Simpsonville, SC 29681

Psychiatric residential treatment facility certification: CCN 42L016

Legal name

EXCALIBUR YOUTH SERVICES LLC-KINGSTREE

Certification status

Active

Provider type (POS)

Psychiatric residential treatment facility

Participating since

May 5, 2011

Last certification

May 26, 2023

Beds

40

Ownership / control type

Government – state

Facility address

1370 North Williamsburg County Highway
Kingstree, SC 29556

Tax ID family

Excalibur Youth Services LLC4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

• Excalibur Youth Services, LLC.

  • Family Medicine Physician
  • Simpsonville, SC
  • NPI 1487174462
  NPD tax ID
• Excalibur Youth Services, LLC.

  • Emotionally Disturbed Childrens' Residential Treatment Facility
  • Greenville, SC
  • NPI 1710063375
  NPD tax ID
• Excalibur Youth Services, LLC.

  dba Azalea Way

  • Mental Illness Community Based Residential Treatment Facility
  • Hendersonville, NC
  • NPI 1073032470
  NPD tax ID

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• David Shane Sherbondy, M.D.

  • Child & Adolescent Psychiatry Physician
  • Greenville, SC
  • NPI 1477572840
  NPD (past)
• Eleanor Theresa Tedesco, MD

  • Psychiatry Physician
  • Myrtle Beach, SC
  • NPI 1700930914
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1232496000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1692662400000",
    "number": "1083852511",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 18346",
            "city": "PALATINE",
            "state": "IL",
            "postal_code": "600550968",
            "telephone_number": "919-703-2829",
            "fax_number": "864-294-1774"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3683 S. INDUSTRIAL DR.",
            "city": "SIMPSONVILLE",
            "state": "SC",
            "postal_code": "29681",
            "telephone_number": "864-688-1133",
            "fax_number": "864-962-6976"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "404 Hampton Ave",
            "address_purpose": "LOCATION",
            "city": "Pickens",
            "state": "SC",
            "postal_code": "296712608",
            "country_code": "US",
            "telephone_number": "864-679-0023",
            "fax_number": "864-294-1774",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1370 N Williamsburg County Hwy",
            "address_purpose": "LOCATION",
            "city": "Kingstree",
            "state": "SC",
            "postal_code": "295567027",
            "country_code": "US",
            "telephone_number": "864-836-7220",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "EXCALIBUR YOUTH SERVICES, LLC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-01-21",
        "last_updated": "2023-08-22",
        "certification_date": "2023-08-22",
        "status": "A",
        "authorized_official_last_name": "WILLIAMS",
        "authorized_official_first_name": "ISABELLE",
        "authorized_official_title_or_position": "MANAGER, REVENUE CYCLE",
        "authorized_official_telephone_number": "919-703-2829"
    },
    "taxonomies": [
        {
            "code": "323P00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Residential Treatment Facility",
            "state": "SC",
            "license": "RTF-0022",
            "primary": true
        },
        {
            "code": "323P00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Residential Treatment Facility",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENT CONTROL",
            "identifier": "RTF-0022",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "RTF055",
            "state": "SC"
        }
    ],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "Raleigh",
            "affiliation": "N",
            "address_1": "3683 S. Industrial Dr.",
            "city": "Simpsonville",
            "state": "SC",
            "country_code": "US",
            "postal_code": "29681",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Broadstep Academy-SC Inc",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Venice Psychiatric Residential Treatment Facility",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Venice Psychiatric Residential Treatment Facility",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Laura Cristina Espinosa, MD
• Arlie Alexander Etherton, DPT, SCS
• Evans Pediatrics LLC
• Cheryl Evans, MD
• Duncan Evans, DPT
• Excalibur Youth Services, LLC.
• Excellence Home Care LLC
• Patrick K Fahey, O.D,
• Jessica Fairfax, LMFT
• Fairview Family Practice

• Psychiatric Residential Treatment Facility in Simpsonville, SC
• Providers in Simpsonville, SC by specialty
• Psychiatric Residential Treatment Facility in South Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.