Healthcare Provider Details

I. General information

NPI: 1629760236
Provider Name (Legal Business Name): MICHELLE BEATTY LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 SAINT ANDREWS RD
COLUMBIA SC
29210-5816
US

IV. Provider business mailing address

900 SAINT ANDREWS RD
COLUMBIA SC
29210-5816
US

V. Phone/Fax

Practice location:
  • Phone: 803-731-4708
  • Fax: 803-612-1206
Mailing address:
  • Phone: 803-731-4708
  • Fax: 803-612-1206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11784
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: