Provider Demographics
NPI:1003414947
Name:CASLEY, CORETTA (MASTER)
Entity Type:Individual
Prefix:
First Name:CORETTA
Middle Name:
Last Name:CASLEY
Suffix:
Gender:F
Credentials:MASTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1011
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SC
Mailing Address - Zip Code:29571-1011
Mailing Address - Country:US
Mailing Address - Phone:843-423-8292
Mailing Address - Fax:843-423-8294
Practice Address - Street 1:424 GUYTON CT
Practice Address - Street 2:
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-6014
Practice Address - Country:US
Practice Address - Phone:843-423-8292
Practice Address - Fax:843-423-8294
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC251S00000XMedicaid