Provider Demographics
NPI:1689298531
Name:ABLE, MARY ETTA CASTLES
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ETTA CASTLES
Last Name:ABLE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:ETTA
Other - Last Name:CASTSLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:1505 BLANDING ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2805 MILLWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-1298
Practice Address - Country:US
Practice Address - Phone:803-234-8596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1-18-30002103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst