Provider Demographics
NPI:1013375708
Name:AVONDALE THERAPY
Entity Type:Organization
Organization Name:AVONDALE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-870-0278
Mailing Address - Street 1:845 SAVANNAH HWY
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:845 SAVANNAH HWY
Practice Address - Street 2:SUITE 1C
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7202
Practice Address - Country:US
Practice Address - Phone:843-870-0278
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC1528Medicaid