Provider Demographics
NPI:1275162042
Name:PEDDICORD, KATHI A (MA, LPC)
Entity Type:Individual
Prefix:
First Name:KATHI
Middle Name:A
Last Name:PEDDICORD
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 OAKBLUFF RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-8449
Mailing Address - Country:US
Mailing Address - Phone:843-813-9650
Mailing Address - Fax:
Practice Address - Street 1:75 SPRINGVIEW LN
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-8154
Practice Address - Country:US
Practice Address - Phone:843-813-9650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7394101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health