=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417607284
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KERSTIN KEENE BLOMQUIST HAFFEY PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2022
-----------------------------------------------------
Last Update Date | 03/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305A OLD BUNCOMBE RD
-----------------------------------------------------
City | TRAVELERS REST
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29690-1817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-305-5990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 305A OLD BUNCOMBE RD
-----------------------------------------------------
City | TRAVELERS REST
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29690-1817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-403-5624
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1709
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------