Healthcare Provider Details

I. General information

NPI: 1265507719
Provider Name (Legal Business Name): ARLENE MAE FREDERICK EDD, RN, LMBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7210L BROAD RIVER RD
IRMO SC
29063-7973
US

IV. Provider business mailing address

7210L BROAD RIVER RD
IRMO SC
29063-7973
US

V. Phone/Fax

Practice location:
  • Phone: 803-749-1576
  • Fax: 803-749-1676
Mailing address:
  • Phone: 803-749-1576
  • Fax: 803-749-1676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2260
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: