Provider Demographics
NPI:1821413980
Name:HERBERT, PAULETTE (LISW-CP)
Entity Type:Individual
Prefix:
First Name:PAULETTE
Middle Name:
Last Name:HERBERT
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 LOBLOLLY PINE DR
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-5940
Mailing Address - Country:US
Mailing Address - Phone:404-944-0810
Mailing Address - Fax:
Practice Address - Street 1:200 W NORTH 1ST ST STE B
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-3250
Practice Address - Country:US
Practice Address - Phone:864-973-1359
Practice Address - Fax:864-973-8965
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC105281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1821413980Medicaid
SC1548683303Medicaid