Healthcare Provider Details

I. General information

NPI: 1194175992
Provider Name (Legal Business Name): ELENA HUTTENLOCHER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 WACCAMAW MEDICAL PARK DR
CONWAY SC
29526-8903
US

IV. Provider business mailing address

164 WACCAMAW MEDICAL PARK DR
CONWAY SC
29526-8903
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-5060
  • Fax: 843-347-3959
Mailing address:
  • Phone: 843-347-5060
  • Fax: 843-347-3959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number11204
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: