Provider Demographics
NPI:1942779046
Name:EDSEL, CYNTHIA DIANNE
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:DIANNE
Last Name:EDSEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CYTHNIA
Other - Middle Name:DIANNE
Other - Last Name:POINDEXTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:141 ATRIUM WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6301
Mailing Address - Country:US
Mailing Address - Phone:803-788-8484
Mailing Address - Fax:803-788-8499
Practice Address - Street 1:10071 BROAD RIVER RD STE B
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2381
Practice Address - Country:US
Practice Address - Phone:803-445-1069
Practice Address - Fax:803-445-1097
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8829225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist