Provider Demographics
NPI:1922039940
Name:ST. ANDREWS PSYCHIATRIC SERVICES, LLC
Entity Type:Organization
Organization Name:ST. ANDREWS PSYCHIATRIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:H
Authorized Official - Last Name:MOAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-327-2716
Mailing Address - Street 1:669 SAINT ANDREWS BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7165
Mailing Address - Country:US
Mailing Address - Phone:843-367-2716
Mailing Address - Fax:843-556-0300
Practice Address - Street 1:669 SAINT ANDREWS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7165
Practice Address - Country:US
Practice Address - Phone:843-367-2716
Practice Address - Fax:843-556-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4054Medicaid
SCGP4054Medicaid