Healthcare Provider Details

I. General information

NPI: 1689011363
Provider Name (Legal Business Name): AGNES MARIA MCDANIEL CAC II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4380 FURMAN FIELD RD
REMBERT SC
29128
US

IV. Provider business mailing address

4380 FURMAN FIELD RD
REMBERT SC
29128-9156
US

V. Phone/Fax

Practice location:
  • Phone: 808-983-8277
  • Fax:
Mailing address:
  • Phone: 808-983-8277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

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

# 1
IdentifierAD18SU
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: