1225711948 NPI number — HORTENSE GRANDERSON MASTERS SOCIAL WORK

Table of content: HORTENSE GRANDERSON MASTERS SOCIAL WORK (NPI 1225711948)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225711948 NPI number — HORTENSE GRANDERSON MASTERS SOCIAL WORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANDERSON
Provider First Name:
HORTENSE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MASTERS SOCIAL WORK
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225711948
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 918
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENNETTSVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-544-4060
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1035 CHERAW HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENNETTSVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-454-0841
Provider Business Practice Location Address Fax Number:
843-454-0635
Provider Enumeration Date:
08/09/2023

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 405127 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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