Provider Demographics
NPI:1891743514
Name:DE HERDER, ELIZABETH FIELDS (OTR L CHT)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:FIELDS
Last Name:DE HERDER
Suffix:
Gender:F
Credentials:OTR L CHT
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:FIELDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR L
Mailing Address - Street 1:1483 TOBIAS GADSON BLVD
Mailing Address - Street 2:SUITE 205B
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4641
Mailing Address - Country:US
Mailing Address - Phone:843-766-6494
Mailing Address - Fax:843-766-6495
Practice Address - Street 1:1483 TOBIAS GADSON BLVD
Practice Address - Street 2:SUITE 205B
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4641
Practice Address - Country:US
Practice Address - Phone:843-766-6494
Practice Address - Fax:843-766-6495
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC000205225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1008Medicaid
SCTH1008Medicaid