Healthcare Provider Details

I. General information

NPI: 1912491580
Provider Name (Legal Business Name): KASEY MOMIER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 FERNWOOD GLENDALE RD STE 62
SPARTANBURG SC
29307-2336
US

IV. Provider business mailing address

2580 LIN DO CT
SUMTER SC
29150-1832
US

V. Phone/Fax

Practice location:
  • Phone: 864-214-2061
  • Fax:
Mailing address:
  • Phone: 803-905-4427
  • Fax: 803-905-4431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number18-54245
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: