1003381732 NPI number — STEPHANIE LANDERS FORREST M.ED, CAC II, MAC

Table of content: STEPHANIE LANDERS FORREST M.ED, CAC II, MAC (NPI 1003381732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003381732 NPI number — STEPHANIE LANDERS FORREST M.ED, CAC II, MAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORREST
Provider First Name:
STEPHANIE
Provider Middle Name:
LANDERS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.ED, CAC II, MAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FORREST
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
LANDERS
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1003381732
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
237 BEECH CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29832-4423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-637-1754
Provider Business Mailing Address Fax Number:
803-637-1727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1612 RIVERS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29649-8513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-227-1001
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/09/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  149 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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