Provider Demographics
NPI:1689981276
Name:HENNAGAN, TABITHA GAIL (LPC)
Entity Type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:GAIL
Last Name:HENNAGAN
Suffix:
Gender:F
Credentials:LPC
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 1:3080 HIGHWAY 15-401 E
Practice Address - Street 2:
Practice Address - City:MC COLL
Practice Address - State:SC
Practice Address - Zip Code:29570-6128
Practice Address - Country:US
Practice Address - Phone:843-523-5751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7984101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC2513Medicaid
SCSCR603OtherMEDICARE