Healthcare Provider Details

I. General information

NPI: 1184863359
Provider Name (Legal Business Name): THERESA ANNE MEDLEY LISW CP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5133 RIVERS AVE
N CHARLESTON SC
29406-6338
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-789-1786
  • Fax:
Mailing address:
  • Phone: 843-789-1620
  • Fax: 843-724-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8561
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: