Healthcare Provider Details

I. General information

NPI: 1326456930
Provider Name (Legal Business Name): ANNA GRACE DEIERLEIN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 PENDLETON ST SUITE 372
COLUMBIA SC
29201-3756
US

IV. Provider business mailing address

1205 PENDLETON ST SUITE 372
COLUMBIA SC
29201-3756
US

V. Phone/Fax

Practice location:
  • Phone: 803-734-4500
  • Fax: 803-734-4538
Mailing address:
  • Phone: 803-734-4500
  • Fax: 803-734-4538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number10811
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: