Provider Demographics
NPI:1003381732
Name:FORREST, STEPHANIE LANDERS (MED, CAC II, MAC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LANDERS
Last Name:FORREST
Suffix:
Gender:F
Credentials:MED, CAC II, MAC
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:LANDERS
Other - Last Name:FORREST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:237 BEECH CREEK RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:SC
Mailing Address - Zip Code:29832-4423
Mailing Address - Country:US
Mailing Address - Phone:803-637-1754
Mailing Address - Fax:803-637-1727
Practice Address - Street 1:1612 RIVERS ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-8513
Practice Address - Country:US
Practice Address - Phone:864-227-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC149101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)