Healthcare Provider Details

I. General information

NPI: 1649618786
Provider Name (Legal Business Name): MARY THERESA VEGLIA LADD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY THERESA VEGLIA MD

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 ASHLEY AVE ROOM 202 MAIN HOSPITAL MSC333
CHARLESTON SC
29425-8905
US

IV. Provider business mailing address

169 ASHLEY AVE RM 202 ROOM 202 MAIN HOSPITAL MSC333
CHARLESTON SC
29425-8905
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-2123
  • Fax:
Mailing address:
  • Phone: 843-792-2123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35789
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number35789
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: