Healthcare Provider Details

I. General information

NPI: 1134663693
Provider Name (Legal Business Name): SUSAN FERTIG LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 GRAND CYPRESS RD UNIT B
SUMMERVILLE SC
29486-2572
US

IV. Provider business mailing address

251 GRAND CYPRESS RD UNIT B
SUMMERVILLE SC
29486-2572
US

V. Phone/Fax

Practice location:
  • Phone: 843-900-4083
  • Fax:
Mailing address:
  • Phone: 301-461-9686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904013618
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20061
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19242
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number20061
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: