MEDICARE: ANDREA JO HENRY DSW, MSW, LISW-CP/S

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	13945	SC
2	1041C0700X	Clinical Social Worker	CW022218	PA

General Provider Information

NPI Number	:	1437961786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA JO HENRY DSW, MSW, LISW-CP/S

Provider Business Mailing Address
First Line	:	298 BRANDYMILL BLVD
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-7226
Country	:	US
Telephone Number	:	843-685-2302
Fax Number	:

Provider Business Practice Location Address
First Line	:	298 BRANDYMILL BLVD
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-7226
Country	:	US
Telephone Number	:	843-685-2302
Fax Number	:

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

Provider Enumeration Date	:	01/23/2025
Last Update Date	:	01/23/2025

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