Provider Demographics
NPI:1376994335
Name:PENZO-SHUMARD, ASYA
Entity Type:Individual
Prefix:
First Name:ASYA
Middle Name:
Last Name:PENZO-SHUMARD
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:PO BOX 1090
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1090
Mailing Address - Country:US
Mailing Address - Phone:843-857-0111
Mailing Address - Fax:843-857-0206
Practice Address - Street 1:737 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SOCIETY HILL
Practice Address - State:SC
Practice Address - Zip Code:29593-8972
Practice Address - Country:US
Practice Address - Phone:843-378-4501
Practice Address - Fax:843-378-4209
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11756101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLW1048Medicaid
SCLW1048Medicaid