Healthcare Provider Details

I. General information

NPI: 1902951684
Provider Name (Legal Business Name): MIKKA WARDDUTTON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIKKA KELLY WARD LPC, LPC-S

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 LADYS ISLAND DR
BEAUFORT SC
29907-1643
US

IV. Provider business mailing address

1606 EDINBURGH AVE
PORT ROYAL SC
29935-1808
US

V. Phone/Fax

Practice location:
  • Phone: 843-812-7199
  • Fax: 843-986-0046
Mailing address:
  • Phone: 843-263-1714
  • Fax: 843-263-1714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4575
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: