Provider Demographics
NPI:1427396282
Name:GOVER, SUE OWEN
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:OWEN
Last Name:GOVER
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 1:300 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-1627
Mailing Address - Country:US
Mailing Address - Phone:803-810-8400
Mailing Address - Fax:803-222-8043
Practice Address - Street 1:300 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:CLOVER
Practice Address - State:SC
Practice Address - Zip Code:29710-1627
Practice Address - Country:US
Practice Address - Phone:803-810-8400
Practice Address - Fax:803-222-8043
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2925103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2925Medicaid