=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568498954
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTA GRABENBAUER LISW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2201 BOUNDARY ST SUITE 307
-----------------------------------------------------
City | BEAUFORT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29902-3860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-263-6124
-----------------------------------------------------
Fax | 843-524-5202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1721 RIVERSIDE DR
-----------------------------------------------------
City | PORT ROYAL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29935-1509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-263-6124
-----------------------------------------------------
Fax | 843-524-5202
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 1420
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------