MEDICARE: KENZA GRACE HADDOCK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	6800	SC

General Provider Information

NPI Number	:	1629610407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENZA GRACE HADDOCK

Provider Business Mailing Address
First Line	:	PO BOX 31537
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-0026
Country	:	US
Telephone Number	:	843-284-7147
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 HIGHWAY 17 N STE 201H
Second Line	:
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-6078
Country	:	US
Telephone Number	:	843-284-7147
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2019
Last Update Date	:	10/12/2019

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Directions to “ KENZA GRACE HADDOCK ” Practice Location

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