Provider Demographics
NPI:1053674143
Name:REDFEARN, TERESA W (MS, LPES, NCSP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:W
Last Name:REDFEARN
Suffix:
Gender:F
Credentials:MS, LPES, NCSP
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 1257
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1257
Mailing Address - Country:US
Mailing Address - Phone:843-917-0495
Mailing Address - Fax:864-751-4179
Practice Address - Street 1:122 E HOME AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-3712
Practice Address - Country:US
Practice Address - Phone:843-917-0495
Practice Address - Fax:864-751-4179
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X
SC4605103TM1800X
4605103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC45-5198811OtherEPI
SC4605Medicaid
SC1265847255OtherGROUP NPI