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General NPI Number Information
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NPI Number | 1629610407
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Entity Type | Individual
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Provider Name | KENZA GRACE HADDOCK
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Gender | Female
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Dates
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Enumeration Date | 10/12/2019
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Last Update Date | 10/12/2019
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Provider Practice Location Address
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Address Line | 1500 HIGHWAY 17 N STE 201H
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City | SURFSIDE BEACH
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State | SC
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Zip | 29575-6078
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Country | US
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Telephone | 843-284-7147
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 31537
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City | MYRTLE BEACH
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State | SC
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Zip | 29588-0026
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Country | US
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Telephone | 843-284-7147
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 6800
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License Number State | SC
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