Healthcare Provider Details

I. General information

NPI: 1265847255
Provider Name (Legal Business Name): TRACY REDFEARN INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 06/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702B W CAROLINA AVE
HARTSVILLE SC
29550-4412
US

IV. Provider business mailing address

702B W CAROLINA AVE
HARTSVILLE SC
29550-4412
US

V. Phone/Fax

Practice location:
  • Phone: 843-917-0495
  • Fax: 843-917-0495
Mailing address:
  • Phone: 843-917-0495
  • Fax: 843-917-0495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number4605
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number4605
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4605
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number4605
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4605
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4605
License Number StateSC
# 7
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4605
License Number StateSC

VIII. Authorized Official

Name: TERESA REDFEARN
Title or Position: LICENSED PSYCHO EDUCATIONAL SPECIAL
Credential: MS, LPES
Phone: 843-917-0495