MEDICARE: DR. LAKEYSA MARIE WRIGHT LISW-CP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904007841	VA
2	1041C0700X	Clinical Social Worker	7334	SC

General Provider Information

NPI Number	:	1215201470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAKEYSA MARIE WRIGHT LISW-CP

Provider Business Mailing Address
First Line	:	755 BURCALE RD APT F7
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-8315
Country	:	US
Telephone Number	:	945-201-1878
Fax Number	:

Provider Business Practice Location Address
First Line	:	314A LAUREL ST
Second Line	:
City	:	CONWAY
State	:	SC
Zip	:	29526-5157
Country	:	US
Telephone Number	:	843-279-0172
Fax Number	:	843-438-4386

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2012
Last Update Date	:	06/16/2022

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