Provider Demographics
NPI:1013297928
Name:ANDERSON, CAROL E O (LISW-CP)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:E O
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 483
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:SC
Mailing Address - Zip Code:29054-0483
Mailing Address - Country:US
Mailing Address - Phone:803-851-0902
Mailing Address - Fax:803-851-7192
Practice Address - Street 1:1905 SUNSET BLVD STE C
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169
Practice Address - Country:US
Practice Address - Phone:803-851-0902
Practice Address - Fax:803-851-7192
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSW69601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7051Medicaid
SCSW1077Medicaid