Provider Demographics
NPI:1417226028
Name:SOUTH CAROLINA INTERVENTIONISTS, INC.
Entity Type:Organization
Organization Name:SOUTH CAROLINA INTERVENTIONISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WARDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MED,, BCBA
Authorized Official - Phone:843-424-1129
Mailing Address - Street 1:1860 AUBURN LN
Mailing Address - Street 2:APARTMENT 19C
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-5159
Mailing Address - Country:US
Mailing Address - Phone:843-424-1129
Mailing Address - Fax:
Practice Address - Street 1:1860 AUBURN LN
Practice Address - Street 2:APARTMENT 19C
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-5159
Practice Address - Country:US
Practice Address - Phone:843-424-1129
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1073705103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty