Healthcare Provider Details

I. General information

NPI: 1780259036
Provider Name (Legal Business Name): KAITLYN MARGARET GRONAUER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PRISMA HEALTH MEDICAL GROUP GENERAL PSYCHIATRY 15 MEDICAL PARK, SUITE 141
COLUMBIA SC
29203
US

IV. Provider business mailing address

PRISMA HEALTH MEDICAL GROUP GENERAL PSYCHIATRY 15 MEDICAL PARK, SUITE 141
COLUMBIA SC
29203
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-4300
  • Fax: 803-434-4062
Mailing address:
  • Phone: 803-434-4300
  • Fax: 803-434-4062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberLL86155
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: