Healthcare Provider Details

I. General information

NPI: 1124848429
Provider Name (Legal Business Name): MARA NOLASCO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2024
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55A SHERIDAN PARK CIR
BLUFFTON SC
29910-6025
US

IV. Provider business mailing address

55A SHERIDAN PARK CIR
BLUFFTON SC
29910-6025
US

V. Phone/Fax

Practice location:
  • Phone: 401-408-0744
  • Fax:
Mailing address:
  • Phone: 843-278-0008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17354
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: