Provider Demographics
NPI:1891929212
Name:SHEALY, KRISTEN M (EDM; CAS; LPC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:SHEALY
Suffix:
Gender:F
Credentials:EDM; CAS; LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 ANNA KNAPP EXT
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-5400
Mailing Address - Country:US
Mailing Address - Phone:843-800-0626
Mailing Address - Fax:843-884-0061
Practice Address - Street 1:1012 ANNA KNAPP EXT
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5400
Practice Address - Country:US
Practice Address - Phone:843-800-0626
Practice Address - Fax:843-884-0061
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5762101Y00000X, 101YP2500X, 1041S0200X
MA4192531041S0200X
CA59454106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist