Provider Demographics
NPI:1467046839
Name:FELLABOM, MADELINE (LPCA)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:FELLABOM
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 RUTLEDGE AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5835
Mailing Address - Country:US
Mailing Address - Phone:843-847-6873
Mailing Address - Fax:
Practice Address - Street 1:198 RUTLEDGE AVE STE 8
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5835
Practice Address - Country:US
Practice Address - Phone:843-847-6873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7406101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health