Provider Demographics
NPI:1083847248
Name:WIESENDANGER, ERIN THOMPSON (LISW)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:THOMPSON
Last Name:WIESENDANGER
Suffix:
Gender:F
Credentials:LISW
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 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:146 E HOSPITAL DR STE 400
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4800
Practice Address - Country:US
Practice Address - Phone:803-936-3300
Practice Address - Fax:803-936-7735
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC106041041C0700X
NCC0064721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1083847248Medicaid
NC6007446Medicaid
SCSW1210Medicaid
SCSW1210Medicaid
NC1083847248Medicaid