Healthcare Provider Details

I. General information

NPI: 1336893957
Provider Name (Legal Business Name): HEATHER ANTLEY MOUNT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

1550 CAROLINA AVE
ORANGEBURG SC
29115-4944
US

IV. Provider business mailing address

1550 CAROLINA AVE
ORANGEBURG SC
29115-4944
US

V. Phone/Fax

Practice location:
  • Phone: 803-533-5480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number95741
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: