Healthcare Provider Details

I. General information

NPI: 1003245234
Provider Name (Legal Business Name): JEFFREY ANTIOHO MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4017 HIGHWAY 17
MURRELLS INLET SC
29576-5032
US

IV. Provider business mailing address

1108 PRESTON PL
MURRELLS INLET SC
29576-7573
US

V. Phone/Fax

Practice location:
  • Phone: 843-685-9228
  • Fax:
Mailing address:
  • Phone: 843-357-0217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10331
License Number StateSC

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: