Healthcare Provider Details

I. General information

NPI: 1144736505
Provider Name (Legal Business Name): DENNIS M PUEBLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2017
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 CHARLIE HALL BLVD
CHARLESTON SC
29414-5832
US

IV. Provider business mailing address

2100 CHARLIE HALL BLVD
CHARLESTON SC
29414-5832
US

V. Phone/Fax

Practice location:
  • Phone: 843-852-4100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000593
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: