Healthcare Provider Details

I. General information

NPI: 1114854825
Provider Name (Legal Business Name): KRISTINE COOPER LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 ASHLEY TOWN CENTER DR STE 203B
CHARLESTON SC
29414-5678
US

IV. Provider business mailing address

PO BOX 87
JOHNS ISLAND SC
29457-0087
US

V. Phone/Fax

Practice location:
  • Phone: 843-847-8112
  • Fax:
Mailing address:
  • Phone: 843-847-8112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17600
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: