Healthcare Provider Details

I. General information

NPI: 1174868533
Provider Name (Legal Business Name): STEPHANIE MURRAY LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 05/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 CHARLOTTE ST
GEORGETOWN SC
29440-2878
US

IV. Provider business mailing address

1101 CHARLOTTE ST PO BOX 2588
GEORGETOWN SC
29440-2878
US

V. Phone/Fax

Practice location:
  • Phone: 240-498-2089
  • Fax:
Mailing address:
  • Phone: 240-498-2089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10078
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierSW1290
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: