Provider Demographics
NPI:1174649511
Name:REDDEN, VICKIE DENSIE
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:DENSIE
Last Name:REDDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E CHEVES ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2526
Mailing Address - Country:US
Mailing Address - Phone:843-317-4089
Mailing Address - Fax:843-317-4096
Practice Address - Street 1:675 N MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-7027
Practice Address - Country:US
Practice Address - Phone:843-661-4879
Practice Address - Fax:843-661-4892
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC376241Medicaid
SC376241Medicaid