Provider Demographics
NPI:1083671440
Name:SVENDSEN, MARY LARSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LARSON
Last Name:SVENDSEN
Suffix:
Gender:F
Credentials:PHD
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Mailing Address - Street 1:2138 ASHLEY PHOSPHATE ROAD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406
Mailing Address - Country:US
Mailing Address - Phone:843-569-2904
Mailing Address - Fax:843-863-0837
Practice Address - Street 1:2138 ASHLEY PHOSPHATE ROAD
Practice Address - Street 2:SUITE 203
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406
Practice Address - Country:US
Practice Address - Phone:843-569-2904
Practice Address - Fax:843-863-0837
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2019-02-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC312103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0065Medicaid