Healthcare Provider Details

I. General information

NPI: 1700145042
Provider Name (Legal Business Name): CATHLEEN KOUVOLO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 05/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9263 MEDICAL PLAZA DR SUITE A
NORTH CHARLESTON SC
29406-7109
US

IV. Provider business mailing address

55 ASHLEY AVE APARTMENT 21
CHARLESTON SC
29401-1269
US

V. Phone/Fax

Practice location:
  • Phone: 843-377-1600
  • Fax: 843-377-1601
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number31151
License Number StateSC

VIII. Authorized Official

Name: CATHLEEN KOUVOLO WINCEY
Title or Position: PSYCHIATRIST
Credential: MD
Phone: 843-614-2675