Provider Demographics
NPI:1992835771
Name:EZZELL, CORA (PHD)
Entity Type:Individual
Prefix:DR
First Name:CORA
Middle Name:
Last Name:EZZELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 LIVE OAK DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4365
Mailing Address - Country:US
Mailing Address - Phone:843-971-8804
Mailing Address - Fax:843-971-8805
Practice Address - Street 1:523 LIVE OAK DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-4365
Practice Address - Country:US
Practice Address - Phone:843-971-8804
Practice Address - Fax:843-971-8805
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC726103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical