Healthcare Provider Details

I. General information

NPI: 1306258579
Provider Name (Legal Business Name): MAUREEN BERNARD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3481 LADSON RD
LADSON SC
29456-4300
US

IV. Provider business mailing address

148 B SAULS STREET
LAKE CITY SC
29560
US

V. Phone/Fax

Practice location:
  • Phone: 843-900-0745
  • Fax: 866-396-4079
Mailing address:
  • Phone: 843-374-0185
  • Fax: 843-374-0189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2719
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: